Fillable Miscellaneous Professional Application (Kinsale Insurance)

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Miscellaneous Professional Application (Kinsale Insurance)

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  • 37 check-boxes
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Page 1 of 4
MISCELLANEOUS PROFESSIONAL LIABILITY APPLICATION
1. Legal name of the business who is the primary applicant and will be the first named insured listed on the policy:
2. Please list all other business/dba names for which you are seeking coverage under this policy:
_________________________________________________________________________________________________
3. Corporation Individual Partnership Municipality For Profit Joint Venture
Other:
4. Please list any names of other entities that you own or manage or that you do business under (such entities are not
requesting coverage under this policy):
5. Primary location address:
6. County of primary location: Date business originally established: __________________________
7. Total number of branches? List all addresses for additional branches:
8. What is your web-site address? www.
_______
9. What is your phone number?
__________________________________________________
10. Has the name or ownership of the entity changed or has any other business been purchased, Yes No
merged or consolidated with the entity within the last 5 years?
11. Does any entity own or control your business or does your business own or control any entity? Yes No
12. During the past five years, has your name been changed or has any other business purchased, Yes No
merged or consolidated with you?
For questions 9-11, please fully explain any “yes” response, including the names, dates, and revenue impact involved:
13. Please list any associations of which you are a member:
1. Please provide a complete narrative description of your operations and services you offer.
2. Most businesses have some exposure to professional liability/errors & omissions allegations. Please provide examples
of such possible allegations that could be made against you or those in your industry.
3. For each possible allegation described above please describe the safeguards or procedures the entity employs to avoid
or reduce the claims and/or exposures identified.
APPLICANT’S INFORMATION
GENERAL INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 4
4. Please help us understand the size of your business. Please provide projections if a new business:
a) Total Gross Revenue: Past 12 months: $ Estimated next 12 months: $
b) Total Payroll: Past 12 months: $ Estimated next 12 months: $
c) Does any single client provide over 25% of gross receipts? Yes No
If “Yes,” please provide the name of the client, the specific dollar value of this work, and a description of the
work performed:
5. Do you have any contracts lasting longer than 12 months? Yes No
If “yes”,
a) How many contracts lasting longer than 12 months?
b) For each contract, what is the duration of the contract and when does it expire?
c) For each contract, please describe the cancellation terms provided to the client?
6. Provide details of the five (5) largest projects undertaken during the last 12 months. If a start-up, please instead
provide a projection of the type and size of projects contemplated:
Name of Client Description of Services Gross Receipts Length of Contract
7. What percentage of your annual gross revenue is comprised of operations outside the United States?
a) For any operations outside the United States, please list each country and the applicable percentage of revenue:
%
8. Please provide the total number of: Officers/Partners Professional Staff Other Staff
Key Staff Professional Licenses Held Years of Experience Length of Employment
9. Please describe any industry groups or associations of which you are a member:
1. Provide your entity’s recent insurance history below.
Insurance Company
Limits Per
Claim/Aggregate
Policy Period
(Month/Day/Year)
Annual Premium
Current Year
Previous Year 1
Previous Year 2
Previous Year 3
Previous Year 4
INSURANCE AND LOSS HISTORY
Page 3 of 4
2. If you are currently insured for errors & omissions coverage, what is your policy’s retroactive/prior acts date?
(month/day/year) _____/_____/_______ If there is no retroactive date, please check here.
If requesting prior acts coverage you will be asked upon binding coverage to provide a copy of your current insurance
declaration page documenting the expiring retroactive date and limits. Prior acts coverage may not be available if
the date of your current retroactive coverage is different from what we have quoted or if there is any gap between
effective dates.
3. Are you being canceled or non-renewed by your current professional liability carrier? Yes No
If yes, please explain why:
4. Requested limits: $100k/$300k $250k/250k $500k/$500k $1M/$1M $2M/$2M
(other)
Requested deductible: $2,500 $5,000 $10,000 $25,000 Other $
5. After inquiry with each person as appropriate, in the last five (5) years, have any claims been made against the person
or entity applying for insurance, or any of your past or present members, partners, officers, directors, employees, or
any predecessors in business?
Yes No
If “yes”, please complete a separate Supplemental Claim form for each claim or suit and include a currently valued
loss run for each claim.
6. After inquiry with each person as appropriate, are you, or any of your partners, officers, directors, or employees, aware
of any circumstances, acts, errors, omissions, or any allegations or contentions of any incident which may result in a
claim? Yes
No
If “yes”, please complete a separate Supplemental Claim form for each claim or suit and include a currently valued
loss run for each claim.
7. After inquiry with each person as appropriate, have you, or any of your partners, officers, directors, or employees been
the subject of any complaint or subject to any disciplinary action by any state licensing agency or other regulatory body
during the past five (5) years? Yes
No
If “yes”, please provide an explanation of the circumstances and penalty involved. If available, please provide a copy
of the complaint, your response, and a copy of the regulatory body’s decision.
FRAUD WARNING
NOTICE TO ALABAMA, 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, NORTH DAKOTA, OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA,
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
information concerning any fact material thereto, may commit a fraudulent insurance act which is a crime in many states.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for
the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any
insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policy holder or
claimant for the purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance
proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of
defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false
information materially related to a claim was provided by the applicant.
Page 4 of 4
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of
claim containing any false, incomplete or misleading information is guilty of a felony of the third degree.
NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or
benefit is a crime punishable by fines or imprisonment, or both.
NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits
a fraudulent insurance act, which is a crime.
NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose
of defrauding the company. Penalties may include imprisonment, fines, or denial of insurance benefits.
NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to
criminal and civil penalties.
NOTICE TO NEW MEXICO APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an 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, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed $5,000 and the stated value
of the claim for each such violation.
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
application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes a any claim
for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
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
concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties.
NOTICE TO TENNESSEE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the
purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
NOTICE TO VIRGINIA APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose
of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant warrants that the
above statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or omit
any material facts.
The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise prior to the effective
date of any policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may be modified or withdrawn
based upon such changes at our sole discretion.
Completion of this form does not bind coverage. Applicant’s acceptance of the company’s quotation is required prior to binding coverage and policy
issuance.
All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by reference into this
application and made a part of this application.
Applicant: Title:
(Must be signed by a Principal, Partner, or Officer of the Firm)
Applicant’s Signature: Date:
Agent/Broker Name:
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Miscellaneous Professional Application (Kinsale Insurance)

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Completed 15 July 2020

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