Fillable MISCELLANEOUS PROFESSIONAL LIABILITY ERRORS & OMISSIONS APPLICATION (RT Specialty)

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MISCELLANEOUS PROFESSIONAL LIABILITY ERRORS & OMISSIONS APPLICATION (RT Specialty)

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  • 16 check-boxes
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MISCELLANEOUS PROFESSIONAL LIABILITY
ERRORS & OMISSIONS APPLICATION
APPLICANT’S INFORMATION:
APPLICANT NAME:
BUSINESS NAME:
INSPECTION CONTACT: PHONE:
MAILING ADDRESS:
INSURED ADDRESS: Same as above
Corporation Individual Partnership Municipality For Profit Joint Venture
Other:
1. A. Year Established_____________________ B. [ ] Individually Owned [ ] Partnership [ ] Corp
Number of Locations_________________________
2. Complete description of operations/services. (Also attach a copy of the firm’s brochures)
3. Indicate the specific types of claims or exposures for which coverage is desired
4. What safeguards or procedures does the firm employ to avoid or reduce the claims and/or exposures identified in
question #4 above?
5. Attach a listing, on the firm’s stationary, of the firm’s five largest projects during the past five years. Include the
client Name, description of services rendered and fees generated from each
6. A. Has the name or ownership of the firm changed or has any other business been purchased, merged or
consolidated with the firm within the last 5 years?
No Yes
B. Is the firm owned or controlled by any other firm or individual?
No Yes
C. Does the firm, or any owner or officer of the firm own, engage in, operate, manage or
No Yes
act as a director or officer of any other business?
D. Has any license held by the firm or any individual ever been suspended or revoked?
No Yes
E. Have any persons proposed for this coverage ever been subject to disciplinary action
No Yes
by any state licensing board, court, regulatory authority, or professional association as
a result of professional activities?
7. Is the firm or any partner, shareholder, principal or employee bonded for handling client funds?
No Yes
8. Within the past five years, has the firm performed any professional services for any client in which any,
shareholder, officer or employee of the firm had any ownership interest, or which he/she controlled, operated or
managed to any extent?
Client Name Type of Business Ownership % Capacity Engagement Annual Fees
E&O-MPL Page 1 of 4 11-01
Submit Application
E&O-MPL Page 2 of 4 11-01
9. Within the past five years, has the firm or any partner, officer, principal or employee had any application for
professional liability insurance denied, or policy cancelled or nonrenewed?
No Yes. If “Yes,” please
provide explanation:_______________________________________________________________________
_________________________________________________________________________________________
10. Has the firm or any past or present owner, partner, shareholder, principal, officer, director or employee ever been
subject to disciplinary action by a state licensing agency or other regulatory body?
No Yes. If “Yes,”
please provide explanation:__________________________________________________________________
____________________________________________________________________________________________
11. Have any claims (including lawsuits) been made against the firm, its predecessors, or past or present owners,
directors, officers, employees or other individuals during the past five years?
No Yes. If “Yes,” please
complete a separate Supplemental Claim Form for each claim or suit.
12. Is the firm aware of any circumstances or any allegations of contentions, which may result in a claim (including
lawsuits) being made against the firm, its predecessors, or past or present owners, directors, officers or other
individuals?
No Yes. If “Yes”, please complete a separate Supplemental Claim Form for each
incident.
13. A. Total Gross Fees: Last Year $___________________ This Year (est) $________________________
B. Total Payroll: Last Year $_____________________ This Year (est) $________________________
C. Does any single client provide over 30% of gross receipts
No Yes.
If “Yes,” please provide details:
___
___
14. What percentage of applicant’s business involves subcontracting work to others?__________% Cost of
subcontracted work _____________________What operations are subcontracted?________________________
15. Individuals – Please list all owner(s), partners, officers, and employees engaged in professional services. Include
part- time employees and all professional staff members. Continue in question 22 if necessary.
Name Title Years in Practice
16. Education, Training, Management:
A. Please attach a resume for each owner, partner, principal and professional/technical employee.
B. Do all employees (including management) attend at least one educational seminar
annually?
No Yes
C. Is educational material presented to, and reviewed with all employees at least semi-
annually?
No Yes
What percentage of employees have less than 2 years business related experience? _____________%
D. Is management active in daily operations?
No Yes
Are staff meetings held at least bi-weekly?
No Yes
Are printed standards of practice and code of ethics adhered to, and copies provided to
all clients?
No Yes
Please, enclose any disclaimers and/or descriptive brochures which are provided to existing or prospective
clients.
17. Membership(s) in Professional Organizations, Associations and Societies:
No Yes
Name(s) of organization:________________________________________________________________________
E&O-MPL Page 3 of 4 11-01
18. Has any person or organization requested to be added to your policy as an additional insured? No Yes
If “Yes”:
[ ] Municipality______________________________Interest/Reason__________________________________
Address________________________________________________________________________________
[ ] Other _______________________________________________________________________________
Address________________________________________________________________________________
19. E & O coverage provided to the firm for the past five years:
From/To Carrier Limit Deductible Premiums Retroactive Date
20. Coverage Requested
Requested Effective Date___________________________________________
Requested Retroactive Date_________________________________________
(If prior acts coverage is desired, a copy of current policy declarations must be attached. This
optional coverage must not exceed 5 years)
Limits of Liability: [ ] $100,000/$100,000 [ ] $300,000/$300,000 [ ] $500,000/$500,000
[ ] $1,000,000/$1,000,000
Deductible: [ ] $1,500 [ ] $2,500 [ ] $5,000 [ ] $10,000
21. Supplemental Information (Use this area to provide additional information)
Question # Additional Information
22. Signatures - THIS APPLICATION MUST BE SIGNED BELOW BY ALL OWNER, PARTNERS OR PRINCIPALS.
The undersigned, being authorized by, and acting on behalf of the firm and all persons or concerns seeking insurance, have
read and understand this application and declare all statements set forth herein are true, complete and accurate. The
undersigned further declares and represents that any occurrence or event taking place prior to the issuance of the policy
applied for, which may render inaccurate, untrue, or incomplete, any statement made herein, will immediately be reported
in writing to the company.
The signing of this application does not bind the undersigned to purchase the insurance, nor does receipt or review of the
application bind the company to issue a policy. It is agreed that if a policy is issued, it is issued in reliance upon the
statements in this application.
REPRESENTATION: I/We represent(s) that the information contained herein is true, and that it shall be the basis of the
policy of insurance and deemed incorporated therein, should the company/underwriter evidence acceptance of this
application by issuance of a policy. I/WE further represent(s) that I/WE have not withheld any information which is
reasonably likely to influence the judgement of the company/underwriter considering this application (i.e. prior claims,
prior difficulties with authorities, cancellations or refusals to renew by insurance companies, prior lapses of coverage,
etc….) If I/WE have withheld any such information, I/WE understand that the coverage may be voided. I/WE further
understand that failure to disclose any information in my/our possession regarding possible acts, errors or omissions
which may lead to a claim, will relieve the insurance company of any obligation under the policy.
E&O-MPL Page 4 of 4 11-01
I/WE hereby authorize the insurance company, it agents and representatives to secure any information from my/our
current and previous insurance carriers.
NO INSURANCE SHALL BE GRANTED UNLESS ALL QUESTIONS ARE FULLY ANSWERED.
* 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 conceals for the
purpose of misleading, information concerning any fact material thereto, may be committing a fraudulent
insurance act, and may be subject to a civil penalty or fine.
* not applicable in all states
Signature & Date: ______________________________________________________________ Date: ______________
Signature & Date: ______________________________________________________________ Date: ______________
Signature & Date: ______________________________________________________________ Date: ______________
Agent Signature: _______________________________________________________________ Date: ______________
Agent Lic #: ________________
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MISCELLANEOUS PROFESSIONAL LIABILITY ERRORS & OMISSIONS APPLICATION (RT Specialty)

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Completed 13 December 2020

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