Fill - Free fillable Miscellaneous Professional Liability Coverage Application (Special Risks) PDF form

NOTICE

ALL LIABILITY COVERAGE PARTS FOR WHICH APPLICATION IS MADE APPLY, SUBJECT TO THEIR TERMS,

ONLY TO CLAIMS FIRST MADE OR DEEMED MADE AGAINST INSUREDS DURING THE POLICY PERIOD OR

ANY EXTENDED REPORTING PERIOD, IF APPLICABLE. THE LIMIT OF LIABILITY AVAILABLE TO PAY

LOSSES WILL BE REDUCED BY THE AMOUNTS INCURRED AS DEFENSE EXPENSES, AND DEFENSE

EXPENSES WILL BE APPLIED AGAINST THE RETENTION AMOUNT. THE COMPANY HAS NO DUTY TO

DEFEND ANY CLAIM UNLESS DUTY–TO-DEFEND COVERAGE IS SPECIFICALLY PROVIDED.

The term Ap

plicant means all co

rporations, organizations or other entities, including subsidiaries, proposed for this

insurance.

I. GENERAL INFORMATION

1. Applicant Information:

Name of Applicant:

Street Address:

City, State, ZIP Code:

Website Address:

Year Applicant’s business was established:

Description of Applicant’s operations:

2. Applicant’s Standard Industrial Classification (SIC) code, if known (4-digit number):

3. Is the Applicant a subsidiary of a foreign parent? Yes No

4. Does the Applicant currently file, or does it anticipate filing in the next 6 months, any

documents with the Securities and Exchange Commission or similar foreign authority

regarding any equity or debt securities? Yes

II. ORGANIZATION INFORMATION

1. Describe all entities the Applicant owns (Check here if not applicable ):

Name

Owned

Year

Started

Description of

Operations

Entity

Type*

*Entity Type: FP=For-Profit (other than Partnership); NP=Non-Profit; GP=General Partnership;

LP=Limited Partnership; LLC=Limited Liability Company

To enter more information, please attach a separate page to the Application.

2. In the next 12 months (or during the past 24 months) is the Applicant contemplating (or

has the Applicant compl

eted or been in the process of completing) the followin

a. Any actual or proposed merger, acquisition, or divestiture? Yes No

b. Any creation of a new business, subsidiary, or division? Yes No

c. Any registration for a public offering or a private placement of securities? Yes No

Page 1 of 5

Miscellaneous Professional Liability

Coverage Application

Page 2 of 5

d. Any reorganization or arrangement with creditors under federal or state law? Yes No

e. Any branch, location, facility, office, or subsidiary closings, consolidations, or layoffs? Yes No

If any of the questions above were answered Yes, please attach an explanation, including the timing, the essential

terms of the event, arrangement, and the surrounding circumstances.

III. PROFESSIONAL INFORMATION

1. Describe, in detail, all professional services offered by the Applicant:

Professional Services

% of

Total Revenue

% of Revenue

Sub-Contracted

% %

To enter more information, please attach a separate page to the Application.

2. Indicate Applicant’s revenue for the following years:

Prior Fiscal Year Current Fiscal Year Estimated for Next Fiscal Year

$ $ $

3. Describe the Applicant’s 5 largest projects or jobs during the past 3 years:

Client Name Services Rendered

Annual Revenue Derived

From the Project or Job

4. If sub-contractors are used, does the Applicant require evidence of professional liability insurance? Yes No

5. Is a written contract or agreement required for each client? Yes No

Yes, please attach a sample. If No, please attach an explanation

detailing

how

responsibilities are defined between the Applicant and their cl

ient.

6. Has the Applicant sued to collect past or overdue fees from clients within the past 2 years? Yes No

Yes, please attach an explanatio

7. Does the Applicant use:

a. A procedure manual? Yes No

b. A formal training program? Yes No

8. Indicate the number of Applicant’s employees:

Principals/Partners, Officers, Professionals Clerical/Non-Professional

Page 3 of 5

9. Indicate the following information for all Principals/Partners, Officers, and professional employees:

Name Title

Professional

Designation

# of Years

Experience

in Practice

# of Years

With

Applicant

To enter more information, please attach a separate page to the Application.

10. List all professional associations to which the Applicant belongs:

IV. CURRENT INSURANCE INFORMATION/REQUESTED INSURANCE TERMS

Requested

Limit

Requested

Retention

Requested

Effective Date

Coverage Currently

Purchased

Current

Insurer

$ $ Yes No

Expiring

Limit

Expiring

Retention

Expiring

Premium

Date Coverage

First Purchased

Current Retroactive

Date

$ $ $

1. What is the Applicant’s preference for defense coverage? Duty to Defend Reimbursement

V. LOSS INFORMATION

1. Is the Applicant or any person proposed for this insurance aware of any fact,

circum

stance, situation, event or act that reasonably could give rise

to a claim

again

st them under the Liability Coverage for which the Applicant is applying? Yes

If Yes, please attach an explanation.

With respect to the information required to be disclosed in response to the question above, the proposed insurance will

not afford coverage for any claim arising from any fact, circumstance, situation, event or act about which any executive

officer of the Applicant had knowledge prior to the issuance of the proposed policy, nor for any person or entity who knew

of such fact, circumstance, situation, event or act prior to the issuance of the proposed policy.

2. Has any person or entity proposed for this insurance been a party to any

profe

ssional liability claims, any disciplinary actions, or been cited by

any

regul

atory agency or professional association during the past 5 years? Yes

Yes, please complete the table below:

Date of

Such

Claim

Nature of

Claim

Amount

Paid

for

Defense

Amount

Sought

or Paid for

Damages

Covered by

Insurance?

Corrective

Procedures

Implemented

Current

Status

$ $ Yes No

To enter more information, please attach a separate page to the Application.

Page 4 of 5

VI. REQUIRED ATTACHMENTS

As part of this Application, please submit the following documents (thes

e documents, and the representations and facts

they contain, are made a part of this Application, whether such documents are physically delivered to the Company by the

Applicant or are obtained by the Company from any public source, including the Internet):

 Copi

es of standard contracts and engagement/proposal letter used with clients if policy limit requested is greater than

$1,000,000

 Biographical sketches/resumes of all Principals, Partners, and key employees if in business less than 3 years

 Brochures, advertisements, or other descriptive literature about the Applicant firm, its operations, and activities, if not

available on website

 Most recent annual financial statement, if:

o Applicant is a public company; or

o Applicant is not a public company, but revenues exceed $7,000,000 or policy limit requested is greater than

$3,000,000

VII. COMPENSATION NOTICE

Important Notice Regarding Compensation Disclosure

For information about how Travelers compensates independent agents, brokers, or other insurance producers, please

visi

t this website: http://www.travelers.com/w3c/legal/Producer_Compensation_Disclosure.html

If you prefer, you can call the following toll-free number: 1-866-904-8348. Or you can write to us at Travelers,

Enterprise Development, One Tower Square, Hartford, CT 06183.

VIII. FRAUD WARNINGS

Attention: Insureds in Alabama, Arkansas, D.C.,

Maryland, New Mexico, and Rhode Island

Any person who knowingly (or willfully in MD) presents a false or fraudulent claim for payment of a loss or benefit or

who knowingly (or willfully in MD) presents false information in an application for insurance is guilty of a crime and may

be subject to fines and confinement in prison.

Attention: Insureds in Colorado

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 policyholder or claimant for the purpose of defrauding or

attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance

proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

Attention: Insureds in Florida

Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an

application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

Attention: Insureds in Kentucky, New Jersey, New York, Ohio, and Pennsylvania

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 commits a fraudulent insurance act, which is a crime and subjects

such person to criminal and civil penalties. (In New York, the civil penalty is not to exceed five thousand dollars

($5,000) and the stated value of the claim for each such violation.)

Attention: Insureds in Louisiana, Maine, Tennessee, Virginia, and Washington

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.

Attention: Insureds in Oregon

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly

presents false information in an application for insurance may be guilty of a crime and may be subject to fines and

confinement in prison.

Page 5 of 5

Attention: Insureds in Puerto Rico

Any person who knowingly and with the intention of defrauding presents false information in an insurance application,

or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or

presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be

sanctioned for each violation with the penalty of a fine of not less than five thousand dollars ($5,000) and not more than

ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should

aggravating circumstances be present, the penalty thus established may be increased to a maximum of five (5) years; if

extenuating circumstances are present, it may be reduced to a minimum of two (2) years.

IX. SIGNATURE SECTION

THE UNDERSIGNED AUTHORIZED REPRESENTATIVE (PARTNER, PRINCIPAL OR OTHER OFFICER

CCEPTABLE TO TRAVELERS) OF THE APPLICANT DECLARES THAT TO THE BEST OF HIS/HER KNOWLEDGE

AND BELIEF, AFTER REASONABLE INQUIRY, THE STATEMENTS SET FORTH IN THE ATTACHED TRAVELERS

NEW BUSINESS OR RENEWAL APPLICATION FOR INSURANCE ARE TRUE AND COMPLETE AND MAY BE

RELIED UPON BY TRAVELERS. IF THE INFORMATION IN ANY APPLICATION CHANGES PRIOR TO THE

INCEPTION DATE OF THE POLICY, THE APPLICANT WILL NOTIFY THE COMPANY OF SUCH CHANGES, AND

THE COMPANY MAY MODIFY OR WITHDRAW ANY OUTSTANDING QUOTATION. THE COMPANY IS

AUTHORIZED TO MAKE INQUIRY IN CONNECTION WITH THIS APPLICATION.

THE SIGNING OF THIS APPLICATION DOES NOT BIND TH

E COMPANY TO OFFER, NOR THE APPLICANT TO

PURCHASE, THE INSURANCE. IT IS AGREED THAT THIS APPLICATION, INCLUDING ANY MATERIAL

SUBMITTED THEREWITH, SHALL BE THE BASIS OF THE INSURANCE AND SHALL BE, IN ALL STATES OTHER

THAN NC AND UT, CONSIDERED PHYSICALLY ATTACHED TO AND PART OF THE POLICY, IF ISSUED. THE

COMPANY WILL HAVE RELIED UPON THIS APPLICATION, INCLUDING ANY MATERIAL SUBMITTED

THEREWITH, IN ISSUING THE POLICY.

ELECTRONICALLY REPRODUCED SIGNATURES WILL BE TREATED AS ORIGINAL.

Signature* of Applicant’s Authorized Representative Name (Printed)

(Partner, Principal or Officer)

tle Date

*IF YOU ARE ELECTRONICALLY SUBMITTING THIS APPLICATION TO TRAVELERS, APPLY YOUR ELECTRONIC

SIGNATURE TO THIS FORM BY CHECKING THE ELECTRONIC SIGNATURE AND ACCEPTANCE BOX BELOW.

BY DOING SO, YOU HEREBY CONSENT AND AGREE THAT YOUR USE OF A KEY PAD, MOUSE, OR OTHER

DEVICE TO CHECK THE ELECTRONIC SIGNATURE AND ACCEPTANCE BOX CONSTITUTES YOUR SIGNATUR

CCEPTANCE, AND AGREEMENT AS IF ACTUALLY SIGNED BY YOU IN WRITING AND HAS THE SAME FORCE

AND EFFECT AS A SIGNATURE AFFIXED BY HAND.

AUTHORIZED REPRESENTATIVE’S ELECTRONIC SIGNATURE AND ACCEPTANCE

X. PRODUCER INFORMATION (ONLY REQUIRED IN FLORIDA, IOWA AND NEW HAMPSHIRE):

oducer Signature Producer Name (Printed)

Age

ncy Name Agency Code License Number

Download
Save PDF to desktop

Email
Email completed PDF

Send for Signing
Email for others to sign

Print
Print document

NAME

Miscellaneous Professional Liability Coverage Application (Special Risks)

View Audit Log
Print With Audit Log
Duplicate Document

Fill Online, Printable, Fillable, Blank Miscellaneous Professional Liability Coverage Application (Special Risks) Form

Related forms

Fillable Miscellaneous Professional Liability Coverage Application (Special Risks)

Fill Online, Printable, Fillable, Blank Miscellaneous Professional Liability Coverage Application (Special Risks) Form

Related forms

First 20 documents completely FREE!