Insurance CFP Application

INSURANCE CFP APPLICATION

Applicant / Insured Information

Policy Details

Requested policy type: Professional Liability Cyber Liability General Liability Employment Practices Liability

Policy period from to

Coverage Options & Endorsements

Select optional coverages to be quoted and considered part of this application. Selection does not bind coverage until accepted and premium paid.

Health & Investment Advice Extension

Fiduciary Liability Endorsement

Cyber Breach Response and Privacy Liability

Exclusions and Limitations

The policy applied for will contain standard exclusions, including but not limited to: intentional wrongful acts, criminal acts, fraud, bodily injury or property damage claims, claims arising from investment products explicitly excluded by endorsement, and claims arising from known facts or circumstances disclosed on this application. Coverage is also subject to policy limits, aggregate limits, sublimits, and conditions.

Applicant acknowledges that failure to disclose material facts, including prior incidents, regulatory inquiries, or criminal convictions, may render coverage void ab initio or permit rescission of any policy issued.

Beneficiary / Designated Payee

Designate a payee for policy proceeds, indemnity, or return premium in the event of death or incapacity as permitted by the policy terms.

Prior Claims, Disciplinary Actions, and Loss Information

In the last 10 years, has the applicant or any principal named in this application had any claim, notice of circumstance, suit, regulatory proceeding, disciplinary action, or criminal conviction?

No known claims, proceedings, or disciplinary actions
Yes — provide details below and attach supporting documentation

Documentation Checklist

Please attach copies of the following as applicable. Submission of this application without required documentation may delay underwriting.

Current resume / CV for principal applicant

Sample client agreement and fee schedule

Firm financial statements (latest)

Prior loss runs / claims ledger

Declarations and Authorization

By signing below the applicant certifies that the information contained in this application and in any attachments is true, correct and complete to the best of the applicant's knowledge and belief. The applicant agrees that this application, together with any attachments and any additional materials submitted to the insurer, shall form the basis of any policy issued and shall be deemed a material representation.

The applicant authorizes any person, firm, insurer, or regulatory authority to release to the insurer or its representatives any records or information requested in connection with this application, including but not limited to prior loss information, disciplinary records, and employment history for underwriting and claim handling purposes. A photocopy or electronic copy of this authorization shall be as effective and valid as the original.

The applicant acknowledges that coverage will not commence until a binder or policy is issued and the required premium is received. If a policy is issued, it may contain additional endorsements, definitions, exclusions, and conditions that further restrict or expand coverage. The insurer retains the right to decline coverage, modify terms, or impose a surcharge based on underwriting review.

Fraud Warning: Any person who knowingly presents false information or omits material information for the purpose of obtaining insurance may be subject to denial of coverage, criminal prosecution, civil penalties, and other remedies as provided by law.

Acknowledgement

Applicant acknowledges that the insurer may rely upon the statements made in this application in determining whether to offer coverage and on what terms. Applicant further acknowledges that any person signing this application on behalf of an entity represents that they are authorized to do so.

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