Application For Emergency Care
Services Professional Liability
1.Name of Applicant
Street Address
Cit
y
State Zip
Applicant’s Web Site Address
2. Type of Organizatio
n
Volunteer Individual Partnership
Corporation For-Profit Non-Profit
Municipality (Fully describe interest, control, financial support.)
Other (Please explain.)
Is Applican
t owned or operated by a hospital?
Yes No
3. Date Established
4. Population of Area Serve
d
Radius of Operation Miles
5. Sales (If applicable.) $
Number of Volunteer Members
Number of Paid Members
6. Has the appli
cant had previous insurance for this enterprise?
Yes No
(If yes, please complete the following.)
Insurance Company Policy Period Limits of Liability Premium
Type of
Coverage
Occurrence or
Claims Made
7. During the pa
st three (3) years, have any claims been presented to your current or prior
Yes No
insurance carrier(s)? If yes, please provide description of claim(s), date of loss, amount(s)
paid and reserved on Attachment to A13.
8. Is the applicant, or any other person for whom insurance is being requested, aware of
Yes No
any circumstances which may result in a claim? If yes, please provide full details
on Attachment to A13.
9. Has the applicant, or any other person for whom coverage is being requested, had any application
Yes No
for liability insurance denied, policy cancelled or non-renewed in the past three (3) years?
If yes, please provide full details on Attachment to A13.
10. Type of Service Ambulance First Responder
Paramedic Alarm Monitoring
Rescue Squad with Ambulance Rescue Squad without Ambulance
Fire Department with Ambulance Fire Department without Ambulance
Individual EMT Individual Paramedic
Dispatch Service for Others Other (Please specify.)
Page 1 of 2 A13 (11/05)
Member Companies of Western World Insurance Group
Western World Insurance Company
Tudor Insurance Company
Stratford Insurance Company
