Professional Liability

Professional Liability Insurance - Application

Abco Insurance Agency
2023 Route 70 West
Cherry Hill, NJ 08002
APPLICATION FOR
PROFESSIONAL LIABLITY INSURANCE
(CLAIMS-MADE FORM)
General Applicant Information
Name of Applicant:
Principal Address:
City: County: State: Zip:
Phone: Website Address:
Does the Applicant practice as:

established:
MM/ DD/ YY/
Email
   
Applicant Practice
Please describe in detail the professional activities for which coverage is desired:
   
Does any member of the Applicant provide professional services other than those mentioned in question 7.?

(If "yes", please provide full details)

    To what professional association(s) does the Applicant belong?       Has any one client (including affiliated clients) account for 25% or more of the Applicant's gross revenues during the past

12 months? If "yes", please provide the name(s) of the client(s) and percentage.

  List the total gross revenues for the past two years derived from those activities in Question 7. In addition, please list

projected revenues for the current year (For insurance agents and brokers, please provide total gross commissions).

 

Year

Amount

a. Current Projected

$

b. Past Fiscal Year

$

c. Second Past Fiscal Year

$

  For the revenue listed in question 11., please provide the approximate percentage derived from each of the activities listed

under Question 7.

 

Activity

% if 11.a. Revenues

 

%

 

%

 

%

  Please include a list of the Applicant's five largest jobs or projects during the past three (3) years. (Do not complete for

Insurance Agents and Brokers)

 
Project / Client Name Service Performed for

Client

Revenue from those

Services

Date Service

Began

Former Employer of

Applicant

(Yes or No)

Pct. of gross revenue
  Staff Information Please provide the following: (Please include all principal and key employee resumes)  
Name of all Principals, Partners, Owners and Key Employees Professional Qualifications Years with Applicant Firm Years in Practice Continuing Education

(Yes or No)

Position with Firm
  Provide information on the Applicant's Staff:
  Full Time Part Time
a. Total Number:

b. Number hired within the past 12 months

c. Number terminated, retired, or resigned within the past 12 months:

  Does the Applicant practice as:

  In the past (5) five years, has any professional liability claim or suit ever been made against the Applicant or any of its

predecessor firms if any? If "Yes", how many ?

Please complete the Claim Supplement and provide currently valued company loss runs.   Does any principal, owner, partner or employee know of any incident, act, error or omission that could result in a claim or

suit against the Applicant or any predecessor firms? If "yes", how many ?

Please complete the Claim Supplement and provide currently valued company loss runs.   Have all matters in Question 17. and 18. been reported to the Applicant's former or current insurer(s) or to the former

Insurer of any predecessor firm or former insurer of a current member of the Firm?

  Has any principal, owner, partner or employee for whom coverage is sought been the subject of a disciplinary complaint

made to any court, administrative agency or regulatory body? (If "yes", provide full details and documentation)

  Please list the Applicant's Professional Liability Insurance Coverage carried during the past three (3) years, including any

periods without coverage.

Name of Insurer

Policy Period

From: MM/DD/YY

To:     MM/DD/YY

Limits of Liability

Deductible / Retention

Premium

  Does the current policy have a prior acts limitation or retroactive date? (This should be the date which the Applicant first

purchased claims made coverage that has been continuously renewed). If "yes", please indicate date:

Desired Effective Date: MM/ DD/ YY/
 

The Applicant declares that the above statement and representations are true and correct, and that no facts have been suppressed or misstated. All written statements and materials furnished to the Company, in conjunction with this application will be incorporated by reference into this application and made part hereof.

This application does not bind the Applicant to buy, or the Company to issue the insurance, but it is agreed that this form shall be the basis of the contract should a policy be issued, and it will be attached to and made part of the policy. The undersigned Applicant declares that if the information supplied on this application changes between the dates of this application and the time when the policy is issued, the Applicant will immediately notify the company of such changes, and the Company may withdraw or modify any outstanding quotations and/or authorization or agreement to bind the insurance.

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Signature of the Insured,

Owner, Partner or Principal

Title

  Date

   

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