Page1of4
MISCELLANEOUSPROFESSIONALLIABILITYAPPLICATION
1. Legalnameofthebusinesswhoistheprimaryapplicantandwillbethefirstnamedinsuredlistedonthepolicy:
_________________________________________________________________________________________________
2. Pleaselistallotherbusiness/dbanamesforwhichyouareseekingcoverageunderthispolicy:

3. Corporation  Individual Partnership Municipality ForProfit JointVenture
Other:
4. Pleaselistanynamesofotherentitiesthatyouownormanageorthatyoudobusinessunderandforwhichno
coverageisbeingappliedfor.

5. Primarylocationaddress:
6. Datebusinessoriginallyestablished:__________________________
7. Totalnumberofbranches? Listalladdressesforadditionalbranches:
_______
8. Whatisyourwebsiteaddress?www. __________________________________________________
9. Hasthenameorownershipoftheentitychangedorhasanyotherbusinessbeenpurchased, Yes No
mergedorconsolidatedwiththeentitywithinthelast5years?
10. Doesanyentityownorcontrolyourbusinessordoesyourbusinessownorcontrolanyentity? Yes
No
11. Duringthepastfiveyears,hasyournamebeenchangedorhasanyotherbusinesspurchased, Yes
No
mergedorconsolidatedwithyou?
Forquestions911,pleasefullyexplainany“yes”response,includingthenames,dates,andrevenueimpactinvolved:


12. Pleaselistallassociationsofwhichyouareamember:

1. Pleaseprovideacompletenarrativedescriptionofyouroperationsandservicesyouoffer.




2. Pleasehelpusunderstandthesizeofyourbusiness.Pleaseprovideprojectionsifanewbusiness:
a) TotalGrossRevenue:Past12months:$ Estimatednext12months:$
b) TotalPayroll:Past12months:$ Estimatednext12months:$
c) Doesanysingleclientprovideover25%ofgrossreceipts? Yes No
If“Yes,”pleaseprovidethenameoftheclient,thedollarvalueofthiswork,andadescriptionofthework
performed:

APPLICANT’SINFORMATION
GENERALINFORMATION
KinsaleInsuranceCompany
P.O.Box17008
Richmond,VA23226
(804)2891300
www.kinsaleins.com
Page2of4
3. Doyousubcontractanyofyourprofessionalservicestootherprofessionals:Yes
No
Ifyouanswered“Yes”,doyouuseawrittencontractYes
No
Doyourequiresubcontractorstocarryinsurancecoveragethatisequaltoorbroaderthanyours?Yes
No
Doyourequireyoursubcontractstonameyouasanadditionalinsuredontheirpolicies? Yes
No
4. Providedetailsofthefive(5)largestprojectsundertakenduringthelast12months.Ifastartup,pleaseinstead
provideaprojectionofthetypeandsizeofprojectscontemplated:
NameofClient DescriptionofServices GrossReceipts LengthofContract
 
 
 
 
 

5. Pleaseprovidethetotalnumberof:Officers/Partners ProfessionalStaff OtherStaff
KeyStaff ProfessionalLicensesHeld YearsofExperience LengthofEmployment





6. Pleaselistanyindustrygroupsorassociationsthatyoubelongto:

1. Provideyourentity’srecentinsurancehistorybelow.
InsuranceCompany
LimitsPer
Claim/Aggregate
PolicyPeriod
(Month/Day/Year) AnnualPremium
CurrentYear
PreviousYear1
PreviousYear2
PreviousYear3
PreviousYear4

2. Ifyouarecurrentlyinsuredforerrors&omissionscoverage,whatisyourpolicy’sretroactive/prioractsdate?
(month/day/year)_____/_____/_______Ifthereisnoretroactivedate,pleasecheckhere.

3. Areyoubeingcanceledornonrenewedbyyourcurrentprofessionalliabilitycarrier?
Yes No 
Ifyes,pleaseexplainwhy:

4. Requestedlimits: $1M/$2M $2M/$2M (other) 
INSURANCEANDLOSSHISTORY
Page3of4
5.
Requesteddeductible: $2,500 $5,000 $10,000 $25,000 Other$
6. Inthelastfive(5)years,haveanyclaimsbeenmadeagainstthepersonorentityapplyingforinsurance,oranyofyour
pastorpresentmembers,partners,officers,directors,employees,oranypredecessorsinbusiness? Yes
No
If“yes”,pleaseprovidedetailsonaseparatepage.
7. Areyou,oranyofyourpartners,officers,directors,oremployees,awareofanycircumstances,acts,errors,omissions,
oranyallegationsorcontentionsofanyincidentwhichmayresultinaclaim? Yes
No
If“yes”,pleaseprovidedetailsonaseparatepage.
8. Haveyou,oranyofyourpartners,officers,directors,oremployeesbeenthesubjectofanycomplaintorsubjecttoany
disciplinaryactionbyanystatelicensingagencyorotherregulatorybodyduringthepastfive(5)years?Yes
No
If“yes”,pleaseprovideanexplanationofthecircumstancesandpenaltyinvolved.Ifavailable,pleaseprovideacopy
ofthecomplaint,yourresponse,andacopyoftheregulatorybody’sdecision.
FRAUDWARNING
NOTICETOALABAMA,ALASKA,ARIZONA,ARKANSAS,CALIFORNIA,CONNECTICUT,DELAWARE,GEORGIA,IDAHO, ILLINOIS,INDIANA,IOWA, KANSAS,
MARYLAND, MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH
CAROLINA,NORTHDAKOTA,OREGON,RHODEISLAND, SOUTH CAROLINA,SOUTHDAKOTA,TEXAS, UTAH, VERMONT,WASHINGTON,WESTVIRGINIA,
WISCONSIN, AND WYOMING APPLICANTS:In
some states, any person who knowingly, and with intent to defraud any insurance company or other
person, files an application for insurance or statement of claim containing any materially false information, or, for the purpose of misleading, conceals
informationconcerninganyfactmaterialthereto,maycommitafraudulentinsuranceactwhich
isacrimeinmanystates.
NOTICETOCOLORADOAPPLICANTS:Itisunlawfultoknowinglyprovidefalse,incompleteormisleadingfactsorinformationtoaninsurancecompanyfor
thepurposeofdefraudingorattemptingtodefraudthecompany.Penaltiesmayincludeimprisonment,fines,denialofinsuranceandcivildamages.
Any
insurancecompanyoragentofaninsurancecompanywho knowingly provides false, incomplete ormisleading facts or information to a policy holder or
claimantforthepurposeofdefraudingorattemptingtodefraudthepolicyholde rorclaimingwithregardtoasettlementorawardpayableforinsurance
proceedsshallbe
reportedtotheColoradoDivisionofInsurancewithintheDepartmentofRegulatoryAgencies.
NOTICE TO DISTRICTOF COLUMBIA APPLICANTS: WARNING:Itis a crime to provide falseor misleadinginformation toan insurerfor thepurpose of
defrauding the insurer or any other person. Penalties include imprisonment and/or fines.
In addition, an insurer may deny insurance benefits if false
informationmateriallyrelatedtoaclaimwasprovidedbytheapplicant.
NOTICETOFLORIDAAPPLICANTS:Any personwhoknowinglyandwithintenttoinjure,defraudordeceive anyinsurancecompanyfiles a statementof
claimcontaininganyfalse,incompleteor
misleadinginformationisguiltyofafelonyofthethirddegree.
NOTICETOHAWAIIAPPLICANTS:Foryourprotection,Hawaiilawrequiresyoutobeinformedthatpresentingafraudulentclaimforpaymentofalossor
benefitisacrimepunishablebyfinesorimprisonment,orboth.
NOTICETO
KENTUCKYAPPLICANTS:Anypersonwhoknowinglyandwithintenttodefraudanyinsurancecompanyorotherpersonfilesanapplicationfor
insurancecontaininganymateriallyfalseinformationorconceals,forthepurposeofmisleading,informationconcerninganyfactmaterialtheretocommits
afraudulentinsuranceact,whichisacrime.
NOTICE
TO LOUISIANA APPLICANTS:Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
presentsfalseinformationinanapplicationforinsuranceisguiltyofacrimeandmaybesubjecttofinesandconfinementinprison.
NOTICETOMAINEAPPLICANTS:It
isacrimetoknowinglyprovidefalse,incompleteormisleadinginformationtoaninsurancecompanyforthepurpose
ofdefraudingthecompany.Penaltiesmayincludeimprisonment,fines,ordenialofinsurancebenefits.
NOTICETONEWJERSEYAPPLICANTS:Anypersonwhoincludesanyfalseormisleadinginformationonanapplication
foraninsurancepolicyissubjectto
criminalandcivilpenalties.
NOTICE TO NEW MEXICO APPLICAN TS:Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
presentsfalseinformationinanapplicationforinsuranceisguiltyofacrimeandmay
besubjecttocivilfinesandcriminalpenalties.
NOTICETONEWYORKAPPLICANTS:Anypersonwhoknowinglyandwithintenttodefraudaninsurancecompanyorotherpersonfilesanapplicationfor
insuranceorstatementof claimcontaining anymateriallyfalse information,orconceals,for the purposeof misleading, information
concerning any fact
materialthereto,commitsafraudulentinsuranceact,whichisacrimeandshallalsobesubjecttoacivilpenaltynottoexceed$5,000andthestatedvalue
oftheclaimforeachsuchviolation.
Page4of4
NOTICE TO OHIO APPLICANTS:Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an
applicationorfilesaclaimcontainingafalseordeceptivestatementisguiltyofinsurancefraud.
NOTICETOOKLAHOMAAPPLICANTS:WARNING:Anypersonwhoknowingly,
andwithintenttoinjure,defraudordeceiveanyinsurer,makesaanyclaim
fortheproceedsofaninsurancepolicycontaininganyfalse,incompleteormisleadinginformationisguiltyofafelony.
NOTICE TO PENNSYLVANIA APPLICANTS:Any person who knowingly and with intent to defraud any insurance company, or
other person, files an
application for insurance or statement of a claim containing any materially false information or conceals for the purpose of misleading, information
concerninganyfactmaterialtheretocommitsafraudulentinsuranceact,whichisacrimeandsubjectsthepersontocriminalandcivilpenalties.
NOTICE TO
TENNESSEE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the
purposeofdefraudingthecompany.Penaltiesincludeimprisonment,finesanddenialofinsurancebenefits.
NOTICETOVIRGINIAAPPLICANTS:Itisacrimetoknowinglyprovidefalse,incompleteormisleadinginformation
toaninsurancecompanyforthepurpose
ofdefraudingthecompany.Penaltiesincludeimprisonment,finesanddenialofinsurancebenefits.
TheApplicantacknowledgesthattheanswersprovidedhereinarebasedonareasonableinquiryand/orinvestigation.TheApplicantwarrantsthatthe
abovestatementsandparticularstogetherwit hanyattachedorappended
documentsaretrueandcompleteanddonotmisrepresent,misstateoromit
anymaterialfacts.
TheApplicantagreestonotifyusofanymaterialchangesintheanswerstothequestionsonthisquestionnairewhichmayarisepriortotheeffective
dateofanypolicyissuedpursuanttothisquestionnaire
andtheApplicantunderstandsthatanyoutstandingquotationsmaybemodifiedorwithdrawn
baseduponsuchchangesatoursolediscretion.
Completion ofthis form doesnot bindcoverage. Applicant’sacceptance of thecompany’s quotationis required prior tobinding coverageandpolicy
issuance.
All written statements and materials furnished
to the company in conjunction with this application are hereby incorporated by reference into this
applicationandmadeapartofthisapplication.
Applicant: Title: 
(MustbesignedbyaPrincipal,Partner,orOfficeroftheFirm)
Applicant’sSignature: Date:
Agent/BrokerName:
click to sign
signature
click to edit