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
No
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
g:
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
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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
If
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
If
Yes, please attach an explanatio
n.
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
No
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
No
If
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
$ $ 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
A
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)
T
i
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
E,
A
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):
Pr
oducer Signature Producer Name (Printed)
Age
ncy Name Agency Code License Number