800.562.8095 Phone . 425.453.8696 Fax
PO Box 3867 . Bellevue, WA 98009 / WWW.GOGUS.COM
Bellevue. Portland. Spokane.
PROPERTY MANAGEMENT SERVICES
Minimum premiums for this coverage start at $2500.00; please have the application completed and forward along with:
1. Resumes of owner/key personnel
2. Copy of the brochure or website
3. Copy of the client contract
When complete, please fax to 425.453.8696
or email to
PROPERTY MANAGEMENTPROF. LIABILITY APPLICATION
800.562.8095 Phone . 425.453.8696 Fax
PO Box 3867 . Bellevue, WA 98009 / WWW.GOGUS.COM
Bellevue. Portland. Spokane.
THIS APPLICATION IS FOR A CLAIMS MADE INSURANCE POLICY
Please read your policy carefully
Name of Applicant
(Entry referred to as applicant throughout this application form)
Address
City State Zip Code
Phone E-Mail
Date established
Please describe in detail the professional services for which coverage is desired:
Have there been any changes in the nature of the Applicant’s business in the last 12 months?
Yes No If yes, please attach details.
What does the applicant see as the potential exposure to a professional liability claim?
List total Gross Receipts derived from the professional services rendered:
Last year
Current year (based on 12 months)
Forecast for next year
Has or will the applicant undertake any work outside of the United States of America? Yes No
Please provide the following:
Name of Partners, Principals, and Key Employees:
Number of Years in Practice (of those specified above)
Is the Applicant a licensed Professional? Yes No
If yes, please advise type of licensed Professional:
Is the Applicant qualified, as required by Law or Regulation? Yes No
Has the Applicant ever had their licence revoked or suspended or been fined or
disciplined in any way or been the subject of any investigation by any form of regulator? Yes No
Does the Applicant use a written contract or letter of engagement with clients?
In all cases Sometimes Never
Does any director, officer, employee, partner or independent/subcontractor of the
Applicant serve as an officer or on the Board of Directors of any client or own any
financial or equity interest in any client of the Applicant? Yes No
If yes, attach an explanation
Does the Applicant anticipate deriving more than 75% of total gross billings
for the coming year from a single client? Yes No
If Yes, advise details on a separate sheet.
Is the Applicant controlled, owned, affiliated or associated with
any other firm, corporation or company? Yes No
If Yes, please provide name(s) and relationship(s):
During the past 12 months has the name of the firm been changed or has any
other business been acquired, merged into, or consolidated with the proposed Applicant? Yes No
Does the Applicant have any Subsidiaries? Yes No
If Yes, Please list on a separate sheet and advise if coverage is to apply to them.
Describe the Applicant’s 3 largest jobs or projects during the past 3 years:
Name of Client Services Provided Gross Billings
Provide the number of principles, partners, officers and professional employees
directly engaged in providing services to clients:
Sub Contractors / Additional Insured(s) information
Provide the number of independent/sub contractors:
What is the total percent of Applicant’s work done by independent contractors and subcontractors:
Does the Applicant desire to provide coverage for independent contractors,
while working on your behalf? Yes No
If Yes to the above, please answer the following questions:
How will the Applicant utilize each independent/subcontractor?
Does the Applicant require Certificates of Professional Liability Insurance
from all independent contractors? Yes No
Additional Insured(s) to be included for Errors and Omissions:
Name Address Relationship to Applicant
Claims Information
Has the Applicant initiated litigation against any of their clients in the past 5 years? Yes No
If Yes, advise how many times you have initiated litigation in the past 5 years along with details for each:
During the past 5 years, has any claim been made or suit brought against the
Applicant, its predecessor(s) in business, or any of its present or former owners,
partners, officers, directors, employees or independent contractors? Yes No
If Yes, please provide details on a separate supplemental claim application.
After enquiry is the applicant aware of any circumstances or allegations that may
lead to a claim, being made against the applicant, its predecessor(s) in business,
or any of its present or former owners, partners, officers, directors, employees
or independent contractors? Yes No
If Yes, please provide details on a separate claim supplement.
Have all claims and circumstances identified in the above questions
already been reported and accepted by a current or past Insurer? Yes No
If No, please attach details.
Professional Liability Insurance Coverage
Has any policy, or Application for professional liability insurance, on the Applicant’s behalf or on the behalf of any of the Applicant’s principles, officers, employees, independent contractors, or on behalf of any predecessor(s) in the Applicant’s business ever been declined, cancelled or renewal refused? Yes No
If Yes, advise details:
Is similar professional liability insurance currently in force? Yes No
If Yes, please advise:
Name of Carrier Limit Retroactive Date Deductible Premium Policy Period
Length of time coverage has continuously been in force:
NOTICE TO THE APPLICANT
The undersigned declares that to the best of his/her knowledge and belief that statements set forth herein are true. The undersigned further declares that any occurrence or event taking place prior to the effective date of the insurance applied for which may render inaccurate, untrue, or incomplete any statement made will immediately be reported in writing to the Underwriters and the Underwriters may withdraw or modify any outstanding quotations. The Underwriter is hereby authorized, but not required to make an investigation and inquiry in connection with the information, statements and disclosures provided in this application. The decision of the Underwriter not to make or to limit any investigation or inquiry shall not be deemed a waiver of any rights by the Underwriter and shall not stop the Underwriter from relying on any statement in this application. The signing of this application does not bind the undersigned to purchase the Insurance, nor
does the review of this application bind the Underwriter to issue a policy. It is understood the Underwriter is relying on this application in the event the policy is issued. It is agreed that this Application shall be the basis of the contract should a Policy be issued and it will be attached and become a part of this Policy.
Signature (Must be an officer of the Applicant)
Date
Name
Title
EO-PROPMGMT (9/07) Page 3 of 6
GENERAL LIABILITY INSURANCE
Does the Applicant currently have General Liability Insurance? Yes No
If Yes, please advise the following:
If Yes, please advise:
Name of Carrier Limit Premium Expiration Date
Is the Applicant involved in the installation of hardware, electrical work, wiring and/or
cable installation of the items for which they are providing consultation services
(including work done by independent contractors on behalf of Applicant)? Yes No
If Yes, please provide percentage of receipts from these services
Additional Insured(s) to be included for General Liability:
Name Address Relationship to Applicant
Has the Applicant had any General Liability claims paid, reserved or pending
during the last 5 years? Yes No
NOTICE TO THE APPLICANT
The undersigned declares that to the best of his/her knowledge and belief that statements set forth herein are true. The undersigned further declares that any occurrence or event taking place prior to the effective date of the insurance applied for which may render inaccurate, untrue, or incomplete any statement made will immediately be reported in writing to the Underwriters and the Underwriters may withdraw or modify any outstanding quotations. The Underwriter is hereby authorized, but not required to make an investigation and inquiry in connection with the information, statements and disclosures provided in this application. The decision of the Underwriter not to make or to limit any investigation or inquiry shall not be deemed a waiver of any rights by the Underwriter and shall not stop the Underwriter from relying on any statement in this application. The signing of this application does not bind the undersigned to purchase the Insurance, nor
does the review of this application bind the Underwriter to issue a policy. It is understood the Underwriter is relying on this application in the event the policy is issued. It is agreed that this Application shall be the basis of the contract should a Policy be issued and it will be attached and become a part of this Policy.
Signature (Must be an officer of the Applicant)
Date
Name
Title
EO-PROPMGMT (9/07) Page 3 of 6
PROPERTY MANAGERS SUPPLEMENTAL APPLICATION
1. Please provide a breakdown below of all properties managed during the past fiscal year. (Number of units, average market value of property).
Number of Units Average Value of Property
Residential Single Family Home $
Apartments $
Condominiums and/or Cooperatives $
Shopping Centers $
Office Buildings $
Commercial or Industrial $
Other, (Please explain) $
2. Does the Applicant or any principal, owner, director, officer, partner or employee
of the Applicant have any ownership in any property managed? Yes No
If Yes, what percentage of ownership? %
3. Is the Applicant certified as a property manager? Yes No
4. Is a budget prepared for each property managed? Yes No
5. Is a credit report obtained on each prospective tenant? Yes No
6. Is a reference check performed with respect to each prospective tenant? Yes No
7. Is the Applicant responsible for performing repairs to any of the property managed? Yes No
If Yes,
a. What is the budgeted amount of repairs to be done on all properties? $
b. What percentage if any of this work is sub-contracted? %
c. Does the Applicant require independent/subcontractors to maintain E&O insurance? Yes No
8. Is the Applicant involved in leasing activity? Yes No
If Yes, who performs the Applicant’s legal work?
It is understood and agreed that this supplemental application shall become a part of the application for Professional Liability Errors & Omissions Insurance.
THE APPLICATION MUST BE SIGNED AND DATED BY AN OWNER, OFFICER OR PARTNER.
Applicant Signature: Date (Mo-Day-Yr):
Name and Title (Please Print):
EO-PROPMGMT (9/07) Page 3 of 6