State *
Section 1 - General Information
1. Number of employees including principals (please list # of full-time, part-time and season employees):
2. Business is an:
3. Date Organized:
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If business started in the past three years, please include resumes of owners/principals.
4. Is the applicant controlled by, owned by, or commonly owned, affiliated or associated with any other organization?
If yes:
a. Are any services provided to such organization(s)?
b. Please provide organization chart and details.
5. During the last year has the applicant been involved in, or are they presently considering or contemplating:
a. any merger, consolidation or acquisition?
If yes, provide a complete explanation detailing liabilities assumed and any professional liability coverage purchased by any predecessor organization:
b. A change in the nature of business operations?
6. During the last year, has the name of the applicant been changed?
a. If yes, provide details:
7. What are the professional designations, societies and organizations to which the applicant and its owners, partners, officers and key employees belong(s)?
8. Within the past year, has the applicant's security been evaluated by a Qualified Security Assessor?
a. If yes, has the applicant corrected or complied with all critical recommendations?
If the applicant has not corrected or complied with all critical recommendations, please provide a timeline for compliance with these recommendations.
b. If no, please describe any steps taken to ensure compliance with Payment Card Industry Data Security Standard.
Section 2 - Professional Activities and Specialty
1. Provide detailed description of all professional services performed or others and indicate the percentage of gross revenues derived from each activity:
2. Is the applicant involved in any other services than described above?
a. If yes, please explain.
c. Annual gross revenues for the last 3 years (please list the last 12 months, 1st prior year and 2nd prior year):
4. Describe applicant's 5 largest jobs in the last 3 years and attach a copy of a sample contract:
5. Does the applicant utilize the services of independent contractors or sub-consultants?
a. If yes, indicate percentage of billings and whether a certificate of professional liability insurance is required of each.
6. Does the applicant, any of its subsidiaries and/or affiliates build, service, repair, install, manufacture, fabricate or sell any product?
7. Is any principal, partner, owner, officer, director, employee, manager/managing member of the applicant a certified public accountant, attorney/lawyer, architect/engineer, provider of any form of healthcare services or manager of those providers?
a. If yes, advise the name of the individual(s), their position(s) with the applicant and the nature of services they perform for clients of the applicant.
8. Please list the policy period, insurer, whether or not claims were made, limits of liability, deductible and retro date of any previous professional liability insurance.
9. Does the applicant carry General Liability Insurance?
a. If yes, provide insurer and limits ($):
b. Does coverage include Products/Completed Operations Hazards?
Section 3 - DataBreach Network and Information Security and Media Liability Information
If DataBreach coverage is desired, please select option and complete this section:
Hold down the Ctrl Key to make multiple selections.
1. Please check all of the following risk management controls that the applicant has in place:
Hold down the Ctrl Key to make multiple selections.
3. Do you have a written policy regarding the setting up of electronic funds transfer?
4. List current and prior DataBreach liability or cyber security insurance.
a. If none, select none.
Section 4 - Claims History
1. After injury, does the applicant have any knowledge of any claims, proceedings arising out of professional services, against the applicant, or any of its principals, partners, owners, officers, etc. during the last 5 years?
a. If yes, attach loss runs and complete details including description of allegations, status of claim, amounts demanded or paid, date of claim, and action taken to prevent the same type of claim in the future.
2. After inquiry, is the applicant or any principal, owner, partner, manager, officer, etc. aware of any fact, circumstance, situation, incident/allegation of negligence/wrongdoing, which might afford grounds for any claim that would fall under proposed?
a. If yes, provide details:
3. Has any insurer cancelled, rescinded, nonrenewed or declined any similar insurance for the applicant, its predecessors, subsidiaries, affiliates or for any other person or organization proposed for this insurance in the last 5 years?
a. If yes, please explain.
4. Has the applicant or any other person or organization proposed for this insurance been involved in or have knowledge of any pending or completed investigative or administrative proceedings or governmental regulatory proceedings, actions or notices?