E&O Insurance Application Form

E&O INSURANCE APPLICATION FORM

Applicant / Insured Information

Date of Birth:

Business / Professional Information

Entity Type: Individual Corporation LLC Partnership Other

Policy Details Requested

Policy Period From:    To:

Coverage Options (select all that apply)

Third-Party Liability for Professional Services Regulatory / Administrative Proceedings Defense Data Breach / Privacy Liability Employment Practices Liability (EPL) Defense Costs / Legal Expenses Subpoena, Expert and Investigation Costs

Prior Acts, Prior Coverage & Claims History

Have any claims, suits, incidents or circumstances been made or reported against the applicant or any predecessor entity, or insured individual within the last 10 years? Yes No

Has the applicant ever had professional liability insurance declined, cancelled, non-renewed or renewal refused? Yes No

Exclusions and Acknowledgements

The policy, if issued, will be subject to the insurer's standard terms, conditions and exclusions. Typical exclusions include intentional acts, criminal conduct, fraudulent acts, bodily injury and property damage (unless otherwise endorsed), and claims arising from matters known prior to inception. Applicant acknowledges that failure to disclose material facts may permit the insurer to deny coverage or void the policy.

Intentional Acts / Dishonesty Criminal Conduct Known Prior Acts / Circumstances

Beneficiary / Payee for Claim Proceeds

Designate beneficiary or payee to receive claim proceeds where applicable or required for payment routing. If multiple beneficiaries are named, percentages must total 100%.

Declarations, Authorizations and Certification

The undersigned applicant declares that the statements made in this application are true, complete and correct to the best of the applicant's knowledge and belief. The applicant understands and agrees that this application shall be the basis of any policy issued and that any material misrepresentation, omission or concealment of fact may give the insurer grounds to deny coverage or rescind the policy in accordance with applicable law.

The applicant authorizes the insurer and its representatives to make any investigation and inquiry in connection with this application, including but not limited to obtaining claim history, loss runs and disciplinary records from prior insurers and regulatory bodies. The applicant further authorizes any person or organization to release such information to the insurer.

The applicant acknowledges that submission of this application does not bind coverage. Coverage is effective only if a policy is issued and premiums are paid as required by the insurer. Acceptance of any premium does not waive the insurer's right to deny coverage if misrepresentations are later discovered.

Fraud Warning: Any person who knowingly presents false information in an application for insurance may be subject to criminal and civil penalties under applicable law.

Applicant authorizes release of prior claims and loss information to the insurer for underwriting and claims handling purposes.

Additional Information

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