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MISCELLANEOUS PROFESSIONAL LIABILITY APPLICATION (Risk Placement Services, Inc.)

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PUA-MPL-APP
MISCELLANEOUS PROFESSIONAL LIABILITY APPLICATION
IF A POLICY IS ISSUED, IT WILL BE ON A CLAIMS-MADE BASIS
NOTICE: THE POLICY PROVIDES THAT THE LIMITS OF LIABILITY AVAILABLE TO
PAY JUDGMENTS OR SETTLEMENTS SHALL BE REDUCED BY DEFENSE EXPENSES,
AND THAT DEFENSE EXPENSES SHALL BE APPLIED AGAINST THE DEDUCTIBLE
AMOUNT.
1. Name of Applicant:____________________________________________________
Address:_____________________________________________________________
____________________________________________________________________
Phone:____________________ Fax:____________________
Web-Site Address:____________________________________________
2. Applicant is: Individual Partnership Corporation Other
3. Year Established:____________
ATTACH COPY OF APPLICANT’S LETTERHEAD
4. Limits of Liability Desired: $____________________ each Claim/Annual Aggregate
5. Deductible Desired: $2,500 $5,000 $10,000 $25,000 Other
6. Please describe in detail the professional services for which coverage is desired:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
7. Please provide the following information for all partners, principals, employed
professionals and key employees (attach separate sheet if necessary).
Name Home Address SS# D/O/B
_______________ _______________ _______________ _______________
_______________ _______________ _______________ _______________
_______________ _______________ _______________ _______________
_______________ _______________ _______________ _______________
PUA-MPL-APP
8. Is, or has, the Applicant engaged in (or does the Applicant intend to be engaged in) any
business or profession other that described in Quest
ion 6?
Yes No
If yes, please supply full details.
9. Please indicate the total annual gross revenues derived from the services described in
Question 6 for the past three years and the projected revenues for the current year:
YEAR REVENUE
a) Current $_______________
b) _______________ $_______________
c) _______________ $_______________
d) _______________ $_______________
9A I) Did the Applicant have a positive Net Income in the past 12 Months
Yes No
If No, Please advise steps being taken to correct the Negative Income.
II) What is the Applicants Overall Net Equity?
Positive Negative.
If Negative, Please advise Net Equity and steps being taken to correct Negative
Equity
III) If Applicant is trading as a Corporation please attach a copy of the latest available
financial report.
10. Is the Applicant now, or in the past (or is it intending to be) controlled or owned by, or to own
or be associated or affiliated with any other firm or business enterprise? Yes No
If yes, please attach an explanation and indicate if any services described in Question 6 are
provided to such firm or business enterprise.
11. During the past three years, has the Applicant’s name been changed, or has the Applicant
purchased, merged or consolidated with any other business or has the Applicant been
purchased? Yes No If yes please attach explanation.
12. Are any changes in the nature or size of the Applicant’s business anticipated over the next 12
months?
Yes No
If yes, please attach an explanation. Changes in size of less than 25% need not be explained.
PUA-MPL-APP
13. Please indicate the number of:
a) Principals, partners, officers and professional employees directly engaged in providing
services to clients. __________ b) All other (non professional/clerical)
employees__________
14. Please provide the following:
Names of All
Partners, Principals, and
Key Employees
Professional
Qualifications/Designations
# Of Years In
Practice
# Of Years
With Applicant
__________________ ________________________ ___________ ___________
__________________ ________________________ ___________ ___________
__________________ ________________________ ___________ ___________
__________________ ________________________ ___________ ___________
Please attach Resume’s covering key Professionals / Employees.
15. Please list professional associations to which Applicant belongs:
___________________________________________________________________________
16. Has the Applicant provided services to any governmental entities? Yes No
If yes, please attach an explanation.
17. Has the Applicant provided services to any employee benefits plans, including any pension plans or
does it plan to do so? Yes No If yes, please attach an explanation.
18. Has the Applicant provided services to any bank, savings and loan or other financial institution, or does
it plan to do so? Yes No If yes, please attach an explanation.
19. Please indicate the Applicant’s five largest jobs/projects during the past three years, showing client’s
name services provided and gross revenues for each:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
20. Does any director, officer, employee or partner of the Applicant serve on the board of directors of any
client of the applicant? Yes No If yes, please attach an explanation.
21. Does the Applicant use a written contract with clients?
In all cases Sometimes No
21A Within Client Contracts (or letters of appointment) does applicant obtain any Hold-Harmless and/or
Limitation of Liability in its favour?
Yes No
PUA-MPL-APP
If Yes, please attach sample copy.
22. Does the Applicant subcontract work to others? Yes No
23. Does the Applicant have a written procedural manual for employees to follow? Yes No
24. Does the Applicant have a formalized training program for newly hired employees?
Yes No
25. Does the Applicant have promotional literature? Yes No If yes, please attach sample copies of all
types.
26. Has the Applicant ever had any errors and omissions or professional liability insurance ever been
declined or cancelled?
Yes No If yes, please attach an explanation
27. Is any errors and omissions or professional liability insurance currently in force?
Yes No.
Provide the following information regarding any coverage during the past five (5) years:
Company Expiration Date Limits Premium
________________ ________________ ________________ ________________
________________
________________ ________________ ________________
________________
________________ ________________ ________________
________________
________________ ________________ ________________
RETROACTIVE DATE OF CURRENT POLICY: ________________
28. Does any director, officer, employee or partner of the applicant have knowledge or information of any
act, error or omission which might reasonably be expected to give rise to a claim?
Yes No If yes, please attach an explanation:
29. Has the Applicant or any director, officer, employee or partner of the Applicant ever been the subject of
disciplinary action as a result of professional activities?
Yes No If yes, please attach an explanation.
30. Please attach a list and status of all errors and omissions claims made during the past five years against
the Applicant or any director, officer, employee or partner of the Applicant. If none, please check here:
None.
31. During the past five years has the applicant been named as a Defendant or Plaintiff in a lawsuit
Yes No If yes, please supply full details.
32
. Do you ever, or do you anticipate offering your Professional Services to clients outside of the United
States of America, its territories and possessions, or Canada?
Yes No If yes, please supply full details including Territorial / Revenue splits.
NB Coverage afforded hereunder is restricted to the United States of America, its territories and
possessions, or Canada. An amendment to this limitation may be available at underwriters
discretion
PUA-MPL-APP
This insurance application, duly completed, together with any supplementary information, must be signed,
in ink, by the Applicant. One signed copy will be attached and form a part of any policy issued. Completion
of this insurance application does not bind or obligate the Company to offer this insurance.
Signing this form, and tendering any payment, does not bind the Insurers or the applicant to complete the
insurance. The insurance application must be signed to be considered for an indication. By signing below
you certify that all information you have provided is correct. You herewith authorize Insurers or their
representatives to gather any additional information they may deem necessary in order to process this
application for quotation or to issue a policy. Your signature below authorizes, but does not obligate
Insurers to obtain additional information or to verify the information provided from any regulatory
agency, provider of services to you or your business, and any financial institution or credit rating company
relating to information about you or your business. By you signature, you herewith authorize the release of
information regarding your losses, any financial information, or any regulatory compliance matters to
Insurers.
NOTICE: IN NEW YORK, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD
ANY INSURANCE COMPANY OR OTHER PERSON FILES AND APPLICATION FOR INSURANCE
CONTAINING ANY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING
INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT
INSURANCE ACT, WHICH IS A CRIME.
The Applicant hereby acknowledges that the persons or entities proposed for insurance are aware that the limits of
liability contained in the policy applied for shall be reduced, and may be completely exhausted, by Defense
Expenses and, in such event, Insurers shall not be responsible for the continued defense of any Claim or liable for
Defense Expenses or for the amount of any judgment or settlement to the extent that any of the foregoing exceed
the limits of liability of such policy
The applicant hereby further acknowledges full awareness of the professional liability insurance policy, its
terms and conditions (especially the policy exclusions) including any endorsements and/or agreed
amendments.
Note:
If the applicant does not understand any part of the Professional Liability coverage then the applicant
should contact their relevant Insurance Broker / Advisor and not
sign the application.
The applicant hereby further acknowledges that the persons or entities proposed for insurance are aware
that Defense Expenses that are incurred shall be applied against the deductible amount.
The undersigned authorized by, and acting on behalf of the applicant and all persons concerned seeking
professional liability insurance, has read and understands this application, and declares all statements set
forth herein are true, complete and accurate.
APPLICANT:_____________________________________
BY:_____________________________________________
TITLE:__________________________________________
DATE:__________________
PUA-MPL-APP
SUPPLEMENTAL CLAIM INFORMATION FORM
APPLICANTS INSTRUCTIONS:
This form is to be completed by Applicant who has been involved in any claim or suit or is aware of any facts,
circumstances, acts, errors or omissions which may give rise to a professional liability claim. COMPLETE ONE
FORM FOR EACH SUCH CLAIM OR CIRCUMSTANCE.
If space is insufficient to answer any question fully, attach separate sheet.
Answer all questions completely.
(PLEASE TYPE OR PRINT)
1. Full name of Applicant:______________________________________________________
2. Full name of individual(s) or firm involved in claim:_______________________________
3. Full name of Claimant:_______________________________________________________
4. Indicate whether: Claim/Suit ( ) or Incident ( )
5. Date of alleged error:_________________________________________________________
6. Date of claim:_______________________________________________________________
7. (a) Description of claim: (Provide enough information to allow evaluation and use a separate exhibit if
additional space is required and include a copy of the complain):_______________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
(b) Description of case and events:_______________________________________________
___________________________________________________________________________
___________________________________________________________________________
8. Additional defendants:________________________________________________________
9. IF CLOSED:
Total loss Paid including Deductible: $___________________________________________
Indicate whether: Court judgment ( ) or Out-of-court settlement ( )
10. IF PENDING
Claimant’s settlement demand $_____________________________________________
Defendant’s offer for settlement $_____________________________________________
Insurer’s loss reserve $_____________________________________________
Deductible $_____________________________________________
Is claim in Suit? Yes ( ) No ( )
If yes, Amount asked in complaint $____________________________________________________
11. Name of insurer:____________________________________________________________
I understand that the information submitted herein become a part of my professional liability application and is
subject to the same certifications, warranties and conditions.
Applicant’s Full Name:___________________________________
By:________________________Date:_______________________
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MISCELLANEOUS PROFESSIONAL LIABILITY APPLICATION (Risk Placement Services, Inc.)

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Completed 30 July 2020

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