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Applicant Information
What is your first name?
*
What is your last name?
*
What is your phone number?
*
What is your email address?
*
What is the name of the applicant?
*
What is the applicant’s mailing address?
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Is the location address different than the mailing address?
*
Yes
No
Please enter the location address of the application
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
What year was the applicant’s business established?
*
What is the legal entity type the applicant operates under?
Corporation
Partnership Sole
Proprietorship
Limited Liability
Company Limited
Partnership S
Corporation
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?
Yes
No
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:
Last Year
Current Year
Next Year
Please select the service(s) the applicant provides.
Abstractor
Answering Service
Appraisers
Barber
Beauty Shop
Book Publisher
Broadcaster
Cemetery
Claims Adjuster
Commercial Photographer
Condominium Wrongful Acts
Cosmetology School
County Recorder
Debt Collection
Dog Grooming
Funeral Service Provider
Graphic Designer
Health or Fitness Club
Home Inspection
Massage Therapist
Medical Appliance/Equipment/Sales
Ministers Professional
Mortgage Broker
Newspaper Publisher
Notary Public
Printer
Real Estate Agent
Religious Institution
Security Guard
Social Service
Surveyor
Tanning Salon
Teacher
Title Agent
Travel Agent
Trustee
Trust in Lending
Veterinarian Technician
Other
Please describe the other service(s).
Revenue
Please provide total gross revenue of Abstractor
Please provide total gross revenue of Answering Service
Please provide total gross revenue of Appraisers
Please provide total gross revenue of Barber
Please provide total gross revenue of Beauty Shop
Please provide total gross revenue of Book Publisher
Please provide total gross revenue of Broadcaster
Please provide total gross revenue of Cemetery
Please provide total gross revenue of Claims Adjuster
Please provide total gross revenue of Commercial Photographer
Please provide total gross revenue of Condominium Wrongful Acts
Please provide total gross revenue of Cosmetology School
Please provide total gross revenue of County Recorder
Please provide total gross revenue of Debt Collection
Please provide total gross revenue of Dog Grooming
Please provide total gross revenue of Funeral Service Provider
Please provide total gross revenue of Graphic Designer
Please provide total gross revenue of Health or Fitness Club
Please provide total gross revenue of Home Inspection
Please provide total gross revenue of Massage Therapist
Please provide total gross revenue of Medical Appliance/Equipment/Sales
Please provide total gross revenue of Ministers Professional
Please provide total gross revenue of Mortgage Broker
Please provide total gross revenue of Newspaper Publisher
Please provide total gross revenue of Notary Public
Please provide total gross revenue of Printer
Please provide total gross revenue of Real Estate Agent
Please provide total gross revenue of Religious Institution
Please provide total gross revenue of Security Guard
Please provide total gross revenue of Social Service
Please provide total gross revenue of Surveyor
Please provide total gross revenue of Tanning Salon
Please provide total gross revenue of Teacher
Please provide total gross revenue of Title Agent
Please provide total gross revenue of Travel Agent
Please provide total gross revenue of Trustee
Please provide total gross revenue of Trust in Lending
Please provide total gross revenue of Veterinarian Technician
Please provide total gross revenue of any Other service
Please select the industry type(s) the applicant does business with.
Aerospace & Defense
Chemical
Construction
Engineering
Consumer Services
Electrical Equipment
Energy Equipment & Services
Financial Services
Government
Healthcare
Information Technology
Manufacturing
Media
Telecommunications
Transportation
Oil, Gas, & Utilities
Retail
Other
Please describe the other industry(s) the applicant does business with.
Does the applicant provide any services over the internet?
Yes
No
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?
Yes
No
Organizational Structure
Is the applicant firm controlled owned or associated with any other firm corporation or company?
Yes
No
Please provide an explanation of the applicant’s relationship with another firm corporation or company.
Are any of the previously described business activities provided to such business enterprise?
Yes
No
Does any person acting on behalf of the applicant also act as a director officer or other executive for any client organization?
Yes
No
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 non-professional employees (Clerks secretaries etc.) are there?
Please answer each of the following questions about the applicant’s key employees.
Key Employee. Information
- What is the 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?
- How long have they been a partner/principle?
Please list all of the professional associations to which the Applicant belongs:
Previous Client Engagements
Previous Client Engagements
Please provide information about the applicant firm’s five (5) largest jobs or projects during the past three (3) years. Please give the following details:
- Project/client Name
- Nature of the services performed
- Contract Value ($)
- Duration (Years/Months)
Subcontractors
Does the applicant’s business involve subcontracting any work to others?
Yes
No
What percentage of the applicant’s revenues come from subcontracting work to others?
Does the application require evidence of professional liability insurance from subcontractors?
Yes
No
Does the applicant always use a written contract upon engagement of a contractor?
Yes
No
Subsidiary Information
Does the applicant own any subsidiaries or have any 50% or more owned joint ventures under management control?
Yes
No
Please enter the following information for each subsidiary or 50% or more owned joint venture under management control.
- Subsidiary Name
- Percent Owned
- Year Started
- Description of Operations
- Entity Type
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?
Yes
No
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?
Yes
No
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?
Yes
No
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?
Yes
No
Please provide an explanation with specifics.
Current Coverage
Does the applicant currently purchase professional liability or miscellaneous E&O insurance?
Yes
No
What is the retroactive date?
Please select the coverage limit the applicant would like for professional liability or miscellaneous E&O.
$25000/$25000
$25000/$75000
$50000/$50000
$50000/$150000
$100000/$100000
$100000/$300000
$200000/$200000
$200000/$600000
$300000/$300000
$300000/$900000
$500000/$500000
$1000000/$1000000
$1000000/$3000000
Other
Please select the deductible the applicant would like for the professional liability or miscellaneous E&O.
$0.00
$500.00
$1000.00
$2500.00
$5000.00
$10000.00
$15000.00
$20000.00
$50000.00
$100000.00
$200000.00
Other
Please select the coverage type the applicant would like.
Claims Made
Occurrence
Does the applicant wish to purchase Prior Acts coverage?
Yes
No
How many years’ prior acts would the applicant like?
Does the applicant want Prior Acts coverage to end at the expiration of this policy?
Yes
No
Does the applicant wish to purchase Consent to Settle coverage?
Yes
No
Does the applicant currently purchase cyber or privacy liability insurance?
Yes
No
What is the retroactive date?
Does the applicant currently purchase media liability insurance?
Yes
No
What is the retroactive date?
Does the applicant currently purchase general liability insurance?
Yes
No
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.
Claims Made
Occurrence
Please list any notable exclusions.
Please upload loss runs (3-5) years.
Max. file size: 128 MB.
Please upload copies of Professional Licenses if applicable.
Max. file size: 128 MB.
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?
Yes
No
Please provide a description.
Please provide the following additional details.
Claim Made or occurrence date
Amount paid or reserved current status
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?
Yes
No
Please provide a description.
Please provide the following additional details.
Claim Made or occurrence date
Amount paid or reserved current status
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?
Yes
No
Please provide a description.
Please provide the following additional details.
Claim Made or occurrence date
Amount paid or reserved current status
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?
Yes
No
Please provide a description.
Please provide the following additional details.
Claim Made or occurrence date
Amount paid or reserved current status
Policy Limits
Please select the options you would like quoted for this professional liability (Errors & Omissions) policy.
$25000/$25000
$25000/$75000
$50000/$50000
$50000/$150000
$100000/$100000
$100000/$300000
$200000/$200000
$200000/$600000
$300000/$300000
$300000/$900000
$500000/$500000
$1000000/$1000000
$1000000/$3000000
Other
Please choose your desired deductible(s) for this proposal.
$0.00
$500.00
$1000.00
$2500.00
$5000.00
$10000.00
$15000.00
$20000.00
$50000.00
$100000.00
$200000.00
Other
Kurt Thoennessen, CAPI
(203) 405-2645
http://ajg.com/
kurt_thoennessen@ajg.com
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