What is your first name? *
What is your last name? *
What is your email address? *
What is your phone number? *
What is the name of the applicant? (I.e. Business name) *
What is the applicant’s mailing address? *
Is the location address different than the mailing address? *
Please enter the location address of the applicant. *
What year was the applicant’s business established? *
What is the legal entity type the applicant operates under?
What is the other legal entity type the applicant operates under?
What date do you want this insurance to be effective? *
MM slash DD slash YYYY
What is the applicant's website address? *
Nature of Operations
Please describe in detail the professional activities for which coverage is desired:
Is the applicant engaged in any business or profession other than as a described in the previous question?
Please describe the other business or profession the applicant is engaged in.
Please provide the total gross revenues for the years indicated which are derived from the applicant’s and any Subsidiaries professional services:
Please check the box next to the sections that apply to the applicant's business. (Select all that apply.) *
Please provide total gross revenue of any Other service.
Please select the industry type(s) the applicant does business with. (Select all that apply)
Please describe the other industry(s) the applicant does business with.
Does the applicant provide any services over the internet?
Please describe the services provided over the internet.
What percentage of the applicant’s revenues are generated through the internet?
Does the applicant derive more than 10% of revenues from state county or local government?
Please provide a description of the business conducted with state, county, or local government.
Organizational Structure
Is the applicant's business controlled, owned or associated with any other firm, corporation or company?
Please provide an explanation of the applicant’s relationship with the other firm, corporation or company.
Are any of the previously described business activities provided to such business enterprise?
Does any person acting on behalf of the applicant also act as a director officer or other executive for any client organization?
Employees
What is the total number of employees the applicant has?
How many principals, partners, officers and professional employees directly engage in providing services to clients?
How many partners/principles/key employees are there? *
What is the first Partner/Principle/Key Employee’s full name? *
What is their title? *
What professional designations/qualifications do they have? *
What is the date they qualified as a partner/principle? *
MM slash DD slash YYYY
How long have they been in practice? *
What is the second Partner/Principle/Key Employee’s full name?
What is their title?
What professional designations/qualifications do they have?
What is the date they qualified as a partner/principle?
MM slash DD slash YYYY
How long have they been in practice?
What is the third Partner/Principle/Key Employee’s full name?
What is their title?
What professional designations/qualifications do they have?
What is the date they qualified as a partner/principle?
MM slash DD slash YYYY
How long have they been in practice?
What is the fourth Partner/Principle/Key Employee’s full name?
What is their title?
What professional designations/qualifications do they have?
What is the date they qualified as a partner/principle?
MM slash DD slash YYYY
How long have they been in practice?
Please upload a file containing the partner/principle/key employee's full names, if convenient.
How many non-professional employees (clerks, secretaries, etc.) are there?
Please list all of the professional associations to which the Applicant belongs:
Previous Client Engagements
Please enter the requested information about the applicant's five (5) largest clients /projects in the previous three (3) years.
What is the first client/project name?
What was the nature of the services performed?
What was the contract value($)?
How long did the project take to complete? (Years/Months)
What is the second client/project name?
What was the nature of the services performed?
What was the contract value($)?
How long did the project take to complete? (Years/Months)
What is the third client/project name?
What was the nature of the services performed
What was the contract value($)?
How long did the project take to complete? (Years/Months)
What is the fourth client/project name?
What was the nature of the services performed
What was the contract value($)?
How long did the project take to complete? (Years/Months)
What is the fifth client/project name?
What was the nature of the services performed
What was the contract value($)?
How long did the project take to complete? (Years/Months)
Subcontractors
Does the applicant’s business involve subcontracting any work to others?
What percentage of the applicant’s revenues come from subcontracting work to others?
Does the application require evidence of professional liability insurance from subcontractors?
Does the applicant always use a written contract upon engagement of a contractor?
Please upload a sample contract.
Subsidiary/Joint Venture Information
Does the applicant own any subsidiaries or have any 50% or more owned joint ventures under management control?
What is the name of the subsidiary?
What percentage of the subsidiary does the applicant own/control?
What year did the subsidiary relationship begin?
Please provide a brief description of the subsidiary's operations.
Please enter the business entity type the subsidiary operates under.
Does the applicant own a second subsidiary or a 50% or more owned joint venture under management control?
What is the name of the second subsidiary?
What percentage of the second subsidiary does the applicant own/control?
What year did the second subsidiary relationship begin?
Please provide a brief description of the second subsidiary's operations.
Please enter the business entity type the second subsidiary operates under.
In the next 12 months (or during the past 24 months) is the applicant contemplating (or has the applicant completed or been in the process of completing) any actual or proposed merger, acquisition, or divestiture?
Please provide an explanation with specifics.
In the next 12 months (or during the past 24 months) is the applicant contemplating (or has the applicant completed or been in the process of completing) any creation of a new business subsidiary or division?
Please provide an explanation with specifics.
In the next 12 months (or during the past 24 months) is the applicant contemplating (or has the applicant completed or been in the process of completing) any reorganization or arrangement with creditors under federal or state law?
Please provide an explanation with specifics.
In the next 12 months (or during the past 24 months) is the applicant contemplating (or has the applicant completed or been in the process of completing) any branch location office closing consolidating or layoffs?
Please provide an explanation with specifics.
Current Errors & Omissions Coverage
Does the applicant currently purchase professional liability or miscellaneous E&O insurance?
What is the retroactive date?
Please select the coverage limit the applicant has in place for professional liability or miscellaneous E&O.
Please select the deductible the applicant has in place for the professional liability or miscellaneous E&O.
Please select the coverage type the applicant would like.
Does the applicant wish to purchase Prior Acts coverage?
How many years’ prior acts would the applicant like?
Does the applicant want Prior Acts coverage to end at the expiration of this policy?
Does the applicant wish to purchase Consent to Settle coverage?
Does the applicant currently purchase cyber or privacy liability insurance?
What is the retroactive date?
Does the applicant currently purchase media liability insurance?
What is the retroactive date?
Does the applicant currently purchase general liability insurance?
What is the name of the insurance company that provides the general liability coverage?
What is the effective date?
MM slash DD slash YYYY
Please enter the current coverage limit per occurrence.
Please enter the current aggregate coverage limit.
Please select the type of policy the applicant has.
Please list any notable exclusions.
Please upload loss runs (3-5) years.
Please upload copies of Professional Licenses if applicable.
Claims
In the past five years has the applicant, its directors, officers, employees or any other person or entity proposed for insurance, ever experienced disciplinary action as a result of professional activities? *
Please provide a description. *
Please provide the following additional details. *
In the past five years has the applicant, its directors, officers, employees or any other person or entity proposed for insurance, ever experienced claims made including any cyber privacy or network security incidents? *
Please provide a description. *
Please provide the following additional details. *
In the past five years has the applicant, its directors, officers, employees or any other person or entity proposed for insurance, ever sued a client to collect fees? *
Please provide a description. *
Please provide the following additional details. *
Is any person or entity proposed for insurance aware of any fact, circumstance or situation which he or she has reason to suppose might give rise to a claim that would fall within the scope of the proposed coverage? *
Please provide a description. *
Please provide the following additional details. *
Policy Limits
Please select the options you would like quoted for this Errors & Omissions policy. (Per Incident/Aggregate)
Please enter the Errors & Omissions liability limit(s) you would like quoted.
Please choose your desired deductible(s) for this proposal.
Please enter your desired deductible for this proposal.
Documents and Comments
Please use this field to upload any relevant insurance documents.
Please enter any additional remarks in the space below.
How did you hear about us?
Please share who referred you to us.
Please share what you typed into Google.
Please share how you heard about us.
Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.
Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes.
