Miscellaneous Professional Liability Application
1. Name of applicant: Requested Effective date of policy:
2. Requested limit of Liability: Deductible:
3. Street Address: ______City: State:
4. Zip Code: ______Web Address:
5. ❑Sole Proprietor ❑Corporation ❑ Partnership ❑Joint Venture ❑Individual ❑Other
6. Are there other office locations? If yes, please provide details: ❑ Yes ❑ No______
7. Date Company was established:______Where is Company licensed/registered?
8. Average number of years of experience of key personnel in this field:
(Please attach resumes of key principles)
9. In the past five (5) years has the name of the Company been changed or has any other business been purchased, or has any
merger or consolidation taken place? If yes, provide details ❑Yes ❑No
10. Describe in detail the professional services provided for which coverage is desired:
11. Please indicate the Applicant’s five (5) largest jobs or projects during the last three (3) years. Please provide the following details:
· Project/client name
· Nature of services performed for the client, and
· Revenues obtained from those services
12. Do you provide any services outside of the United States? ❑Yes ❑No If yes, please provide the percentage of work annually along with details of the services. ______
13. List all Subsidiaries for which coverage is desired. For purposes of completing this question, Subsidiary means any entity that is not formed as a joint venture of which the Applicant owns or has the right to vote more than 50% of the outstanding voting securities representing the present right to vote for election of directors, or the managers or members of the board of managers or equivalent executives of a limited liability company or partnership, on or before the inception date of the Policy. Please provide percentage ownership by Applicant:
Subsidiary Name / Percentage of Ownership / Acquisition or Formation Date / Services Performed by the Subsidiary14. Is the applicant engaged in any business or profession other than described in question #10 above? ❑Yes ❑No
If yes, please provide details by separate via separate attachment to this application ______
15. a) Do you own, control, and/or manage any other business entity(ies)? ❑Yes ❑No
b) Do you provide any services to such business entity(ies)? ❑Yes ❑No
c) Does any employee of the applicant serve on the Board of Directors of any client of the applicant? ❑Yes ❑No Provide detailed explanation to any “Yes” response(s)______
Miscellaneous Professional Liability Application
16. Do you require a written contract or agreement for services with your clients? (If yes, answer 13a-13d)
(If yes, please attach a sample copy of the contract or agreement) ❑ Yes ❑ No
i. Hold harmless or indemnity agreements inuring to your benefit? ❑ Yes ❑ No
ii. Hold harmless or indemnity agreements inuring to your client’s benefit? ❑ Yes ❑ No
iii. Guarantees or warranties? ❑ Yes ❑ No
iv. Specific description of the services you will provide? ❑ Yes ❑ No
17. Gross revenues current year $ Prior completed year $______
Next year projected $
18. Loss controls (all locations) – do you utilize a procedures manual? ❑ Yes ❑ No
19. What additional safeguards or procedures do you employ to avoid liabilities or losses?
20. Number of employees who are: Full Time: Part Time: Sub Contractors:
If the firm is employing subcontractors, please provide the percentage of revenues derived from said activities. What safeguards does the applicant maintain in order to verify that the subcontractors carry their own E&O? Is this a prerequisite before employing a sub? Please explain.
CLAIMS HISTORY/EXPERIENCE: (For questions 21-23 answered yes, please complete a Claim Supplement for each claim, circumstance, act, error or omission)
21. Have any claims or suits been made during the past five (5) years against the Applicant or any of its predecessors in business, subsidiaries or affiliates or against any of the past or present partners, owners, officers, salespersons or
employees? ❑ Yes ❑ No
22. Is the Applicant aware of any circumstances, alleged acts, errors or omissions, or of any offenses which may reasonably be expected to result in a claim being made against the persons/entities described above?.❑ Yes ❑ No
23. Has the Applicant or any of its predecessors in business or subsidiaries or affiliates or any of the past or present partners, owners, officers, salespersons or employees been investigated and/or cited by any administrative or regulatory agency for
violations arising out of their activities? ❑ Yes ❑ No
24. Have all matters in Questions 21 and 22 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 Applicant? ❑ Yes ❑ No
25. Have any of the Applicant’s clients within the last five (5) years refused to pay, stopped paying, or requested a refund due to
alleged problems with the Applicant’s products or services? ❑ Yes ❑ No
26. Has the Applicant within the last five (5) years sued any of its clients for nonpayment? ❑ Yes ❑ No
If yes, provide details: ______
______
27. Please provide the following information for similar insurance, if any, carried during the last five (5) years. If none carried, state so.
Policy Period Renewal Date Carrier Limit Deductible Premium
Miscellaneous Professional Liability Application
28. Has any application for insurance similar to the insurance sought by this application been made by or on behalf of the Applicant or any of its predecessors in business or present partners, owners, officers, sales personnel or employees even been declined or
has any such insurance ever been canceled or renewal refused? (If yes, provide details)
U Yes U No
29. a. Please provide the following information for your general liability coverage (CGL) currently in force and for the immediate past three (3) years.
Policy Period Renewal Date Carrier Limit Deductible Premium
b. Does it include coverage for products and completed operations hazards? ❑Yes ❑ No
30. Please provide the name and contact information of the person who should be contacted in the event of a Claim/Incident.
(____) -
Name Direct Dial
E-Mail AddressMailing Address
REQUIRED DOCUMENTS CHECKLIST: HAVE YOU ATTACHED THE FOLLOWING?
Any additional details? ❑ Yes ❑ No ❑ N/A
Copies of standard contract with clients? ❑ Yes ❑ No
Copies of resumes of key personnel including any applicable continuing education and/or training completed?... ❑ Yes ❑ No
Any marketing materials providing information about the services you perform? ❑ Yes ❑ No
Any person who knowingly and willfully presents false information in an application for insurance may be guilty of insurance fraud and subject to fines and confinement in prison.
THE APPLICANT REPRESENTS THAT THE ABOVE STATEMENTS, FACTS AND ATTACHED MATERIALS ARE TRUE AND THAT NO MATERIAL FACTS HAVE BEEN OMITTED, SUPPRESSED, OR MISSTATED. ALL OF THE STATEMENTS AND MATERIALS PROVIDED TO UNDERWRITERS IN AND WITH THIS APPLICATION ARE DEEMED A PART OF AND INCORPORATED INTO THE APPLICATION.
Miscellaneous Professional Liability Application
COMPLETION AND SUBMISSION OF THIS APPLICATION TO UNDERWRITERS DOES NOT BIND COVERAGE. THE PROVISION OF A QUOTATION BY UNDERWRITERS AND THE ACCEPTANCE BY THE APPLICANT OF THE QUOTATION IS REQUIRED FOR THE BINDING OF COVERAGE AND ISSUANCE OF THE POLICY
The undersigned certifies that he or she is an authorized representative of the Applicant identified in Item 1 of the Application and certifies that he or she has made reasonable inquiry to obtain the answers to these questions. He or she certifies that the answers are true, correct and complete to the best of his or her knowledge and belief.
Applicant
By:[Please print name]
Position:
Signature: Date:
Agent or Broker:
By:
Please send all submissions to .
Miscellaneous Professional Liability Application
STATE FRAUD WARNINGS IN APPLICATIONS
NOTICE TO ALASKA APPLICANTS: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incompetent, or misleading information may be prosecuted under state law.
NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof.
NOTICE TO ARKANSAS APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
NOTICE TO ARIZONA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss is
subject to criminal and civil penalties.
NOTICE TO CALIFORNIA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or information
to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include
imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who
knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of
defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award payable for insurance
proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: It is a crime to provide false or misleading information to an
insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In
addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the
applicant.
NOTICE TO DELAWARE APPLICANTS: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony.
MPL-MF-001 (10/14)
Miscellaneous Professional Liability Application
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insurance company files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony of the third
degree.
NOTICE TO IDAHO APPLICANTS: Any person who knowingly, and with intent to defraud any insurance company, files a
statement containing any false, incomplete, or misleading information is guilty of a felony.
NOTICE TO INDIANA APPLICANTS: A person who knowingly and with intent to defraud an insurer files a statement of claim
containing any false, incomplete, or misleading information commits a felony.
NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other
person files a statement of claim containing any materially false information or conceals, for the purpose of misleading,
information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.
NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or
benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines
and confinement in prison.
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly and willfully presents a false or fraudulent claim for payment
of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime
and may be subject to fines and confinement in prison.
NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, or denial of insurance
benefits.
NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud against an
insurer is guilty of a crime.
NOTICE TO NEW HAMPSHIRE APPLICANTS: Any person who, with a purpose to injure, defraud or deceive any insurance
company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and
punishment for insurance fraud as provided in section 638:20.
MPL-MF-001 (10/14)
Miscellaneous Professional Liability Application
NOTICE TO NEW JERSEY APPLICANTS: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.
NOTICE TO NEW MEXICO APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other
person files an application for insurance or statement of claim containing any materially false information, or conceals for the
purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime,
and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each
violation.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an
insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with any intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information
is guilty of a felony.
NOTICE TO OREGON APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or another
person, files an application for insurance or statement of claim containing any materially false information, or conceals
information for the purpose of misleading, commits a fraudulent insurance act, which may be a crime and may subject such
person to criminal and civil penalties.