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Return Applications to:
Notary Rotary
500 New York Ave
Des Moines, IA 50313
Ph. 877-349-6588 Fax 877-349-6590
Email: quotes@notaryrotary.com
MISCELLANEOUS PROFESSIONAL LIABILITY APPLICATION
NOTICE: THE POLICY FOR WHICH YOU ARE APPLYING IS WRITTEN ON A CLAIMS-MADE AND REPORTED
BASIS. ONLY CLAIMS FIRST MADE AGAINST THE INSURED AND REPORTED TO THE COMPANY DURING THE
POLICY PERIOD ARE COVERED SUBJECT TO THE POLICY PROVISIONS.
THE LIMITS OF LIABILITY STATED IN THE POLICY ARE REDUCED, AND MAY BE EXHAUSTED, BY CLAIMS
EXPENSES. CLAIMS EXPENSES ARE ALSO APPLIED AGAINST YOUR RETENTION, IF ANY. IF YOU HAVE ANY
QUESTIONS ABOUT COVERAGE, CONTACT NOTARY ROTARY.
INSTRUCTIONS:
PLEASE TYPE OR PRINT ALL ANSWERS CLEARLY. ANSWER ALL QUESTIONS COMPLETELY, LEAVING NO
BLANKS. IF THERE IS INSUFFICIENT SPACE TO COMPLETE AN ANSWER, PLEASE CONTINUE ON A SEPARATE
SHEET INDICATING THE QUESTION NUMBER. IF ANY QUESTIONS, OR ANY PART THEREOF, DO NOT APPLY,
PRINT N/A IN THE SPACE. INSERT CHECKS IN YES OR NO ANSWER BOXES, IF ANY. THIS APPLICATION MUST
BE COMPLETED, SIGNED, AND DATED BY AN AUTHORIZED OFFICER OF YOUR FIRM. UNDERWRITERS WILL
RELY ON ALL STATEMENTS MADE IN THIS APPLICATION.
THE INFORMATION REQUESTED IN THIS APPLICATION IS FOR UNDERWRITING PURPOSES ONLY AND DOES
NOT CONSTITUTE NOTICE TO THE COMPANY UNDER ANY POLICY OF A CLAIM OR POTENTIAL CLAIM. ALL
SUCH NOTICES MUST BE SUBMITTED TO THE COMPANY PURSUANT TO THE TERMS OF THE POLICY, IF AND
WHEN ISSUED.
SECTION I: BACKGROUND INFORMATION
1. Name of applicant: ________________________________________
2. Street Address: _______________________________________________________
City: ____________________________ State: ______ Zip: ____________
Phone: __________________ Website Address: _________________________________
E-mail Address: ___________________________________________
3. Date Established: __________________
(If business has been in operation less than 3 years, please provide the resume of a principal, partner or
key employee.)
4. Is the Applicant controlled, owned, affiliated or associated with any other firm, corporation or company?
[ ] Yes [ ] No
If Yes, please provide name(s) and relationship(s):
NOTARY ROTARY
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5. Does the applicant have any subsidiaries?
[ ] Yes [ ] No
If yes, please list below and advise if coverage is to apply to them.
6. Applicant is a:
[ ] Corporation [ ] Partnership [ ] Individual [ ] LLC [ ] Non-Profit
SECTION II: ORGANIZATION OPERATIONS DETAILS
7. Please describe in detail the professional services for which coverage is desired:
8. (a) List total gross receipts derived from activities in Question #7 (start-ups please provide best
estimates):
Gross Receipts
Last Year: _______________
Current Year (based on 12 months): _______________
Forecast for Next Year: _______________
(b) Please indicate the percent of receipts listed in 8a from foreign operations (i.e. outside of the U.S. and
its territories)
Foreign Receipts: _______________
9. Describe the 3 largest jobs or projects during the past 3 years
Name of Client Services Provided Gross Billings
a. __________________________ ____________________ ______________
b. __________________________ ____________________ ______________
c. __________________________ ____________________ ______________
10. Is the Applicant a licensed Professional (i.e. Lawyer, Accountant…)?
[ ] Yes [ ] No
If Yes, advise type of licensed Professional: ________________________________________
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11. (a) Number of principals, partners, officers and professional employees directly engaged in providing
services to clients: ________________
(b) Number of independent/subcontractors: __________________
12. Please answer the following questions regarding the use of independent contractors:
(a) The total percentage of work done by independent/subcontractors: __________ %
(b) Do the independent/subcontractors work exclusively for the Applicant? [ ] Yes [ ] No
(c) Do the independent/subcontractors provide the same services as the applicant? [ ] Yes [ ] No
If No, please explain:
(d) Are all independent/subcontractors required to carry errors and omissions insurance?
[ ] Yes [ ] No
(e) Does the Applicant desire to provide coverage for independent/subcontractors (including them as
named insured(s) on the policy) while working on the Applicant’s behalf? [ ] Yes [ ] No
13. Please provide the following:
Name of Partners/ Professional
Key Employees and Qualifications/
Independent/ Subcontractors Designations # of Years in Practice
a. __________________________ ________________ ______________
b. __________________________ ________________ ______________
c. __________________________ ________________ ______________
d. __________________________ ________________ ______________
e. __________________________ ________________ ______________
14. Does any director, officer, employee, partner, or independent/subcontractor of the Applicant serve as an
officer or on the Board of Directors of any client or own any financial or equity interest in an client of the
Applicant? [ ] Yes [ ] No
If Yes, please explain:
15. What do you see as your potential exposure to a professional liability claim?
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16. Does the Applicant use a written contract or letter of engagement with clients?
[ ] In all cases [ ] Sometimes [ ] Never
17. Additional Insured(s) to be included for Errors and Omissions (list name, address and relationship to
Applicant):
18. Has any prospective insured ever had their license revoked or suspended or been fined or disciplined in
any way or been the subject of any investigation by any regulating body related to their profession?
[ ] Yes [ ] No
If yes, please explain:
SECTION III: CLAIMS INFORMATION
Do not complete this section if this is an application for a renewal policy at the same limit of liability with one of
the USLI companies.
19. Have you initiated litigation against any of your clients in the past 5 years?
[ ] Yes [ ] No
If Yes, please advise how many times you have initiated litigation in the past 5 years along with details for
each:
20. During the past 5 years, has any claim been made or suit brought against the Applicant, its predecessor(s)
in business, or any of its present or former owners, partners, officers, directors, employees or independent
contractors? [ ] Yes [ ] No
If Yes, please provide details:
21. Is any owner, partner, officer, director, employee or independent contractor aware of any circumstance,
allegation, contention, or incident which may result in a claim being made against the Applicant, its
predecessor(s) in business, or any of its present or former partners, owners, officers, directors, employees
or independent contractors? [ ] Yes [ ] No
If Yes, please provide details:
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SECTION IV: CLAIMS INFORMATION
22. Has any Policy or Application for professional liability insurance on your behalf or on the behalf of any of
your principals, officers, employees, independent contractors, or on behalf of any predecessor(s) in
business ever been declined, cancelled or renewal refused? (Not applicable in Missouri.)
[ ] Yes [ ] No [ ] N/A
If Yes, please provide details:
23. Is similar professional liability insurance currently in force? [ ] Yes [ ] No
If Yes, please complete:
Name of Carrier: __________________________________________
Limit: __________________________
Retroactive Date (if any): ____________________
Deductible: _________
Premium: __________
Policy Effective Date: _______________
Policy Expiration Date: _______________
Length of time coverage has been continually in force: _____________________
NOTICE: IN NEW YORK, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER
PERSON FILES AN 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 AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.
BY SIGNING THIS APPLICATION, THE APPLICANT REPRESENTS TO THE COMPANY THAT ALL STATEMENTS MADE IN THIS APPLICATION
AND ATTACHMENTS HERETO ABOUT THE APPLICANT AND ITS OPERATIONS ARE TRUE AND COMPLETE, AND THAT NO MATERIAL
FACTS HAVE BEEN MISSTATED OR MISREPRESENTED IN THIS APPLICATION, SUPPRESSED OR CONCEALED. THE UNDERSIGNED
AGREES THAT IF AFTER THE DATE OF THIS APPLICATION AND PRIOR TO THE EFFECTIVE DATE OF ANY POLICY BASED ON THIS
APPLICATION, ANY OCCURRENCE, EVENT, OR OTHER CIRCUMSTANCE SHOULD RENDER ANY OF THE INFORMATION CONTAINED IN
THIS APPLICATION INACCURATE OR INCOMPLETE, THEN THE UNDERSIGNED SHALL NOTIFY THE COMPANY OF SUCH OCCURRENCE,
EVENT OR CIRCUMSTANCE AND SHALL PROVIDE THE COMPANY WITH INFORMATION THAT WOULD COMPLETE, UPDATE, OR CORRECT
SUCH INFORMATION. ANY OUTSTANDING QUOTATIONS MAY BE MODIFIED OR WITHDRAWN AT THE SOLE DISCRETION OF THE
COMPANY.
COMPLETION OF THIS FORM DOES NOT BIND COVERAGE. THE APPLICANT’S ACCEPTANCE OF THE COMPANY’S QUOTATION IS
REQUIRED BEFORE THE APPLICANT MAY BE BOUND AND A POLICY ISSUED. THE APPLICANT AGREES THAT THIS APPLICATION, IF THE
INSURANCE COVERAGE APPLIED FOR IS WRITTEN, SHALL BE THE BASIS OF THE CONTRACT WITH THE INSURANCE COMPANY, AND BE
DEEMED TO BE A PART OF THE POLICY TO BE ISSUED AS IF PHYSICALLY ATTACHED THERETO. THE APPLICANT HEREBY AUTHORIZES
THE RELEASE OF CLAIMS INFORMATION FROM ANY PRIOR INSURERS TO THE COMPANY.
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Applicant Signature _____________________________________________ Date ______ / ______ / ______
MM DD YY
(Must be signed by an Owner, Partner, Director or Officer of the Named Insured.
It is agreed the signer has authority to act on behalf of all insureds.)
Print Name ________________________________________________________
Print Title ________________________________________________________
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