Insurance E&O Application

INSURANCE ERRORS & OMISSIONS (E&O) APPLICATION

Applicant / Insured Information

Applicant Name:

Individual    Corporation    LLC    Partnership    Other:

Contact Name:    Title:

Phone:    Email:

State or Jurisdiction of Formation:    Date Formed:

Applicant Date of Birth (if individual):    Years in Business:    Number of Employees:

Description of Professional Services

Consulting    Design / Engineering    IT / Software Services    Insurance Brokerage / Agency    Accounting / Tax Advisory

Legal Services    Real Estate Services    Other:

Policy & Coverage Details Requested

Desired Limit per Claim:    Desired Aggregate Limit:    Desired Deductible:

Retroactive Date (if applicable):    Requested Effective Date:    Requested Expiration Date:

Prior Acts Coverage Requested: Yes    No

Business Operations & Financials

Percentage of revenue from largest client: %    Percent of engagements performed remotely: %

Claims, Loss History & Prior Insurance

Prior E&O Insurance in past 5 years: Yes    No

Any claims, suits, or administrative actions in the last 5 years: Yes    No

Risk Management & Controls

Do you use written engagement letters or contracts with every client? Yes    No

Are client deliverables reviewed by a designated supervisor? Yes    No

Exclusions, Notices and Applicant Certification

The applicant warrants that the information contained in this application is true, complete and correct to the best of the applicant's knowledge. The applicant understands that this application and any attachments shall be the basis of any policy issued and will be incorporated in full by reference. Any material misrepresentation, omission or incorrect statement may void coverage or give the insurer the right to rescind the policy or deny coverage for related claims.

By signing this application the applicant authorizes the insurer or its representatives to obtain loss history, claims information and underwriting information from prior insurers, regulatory authorities and any other relevant sources. The applicant agrees to provide upon request any additional information required for underwriting including contracts, sample engagement letters and financial information.

The applicant acknowledges that coverage may be subject to standard policy exclusions including but not limited to dishonest, fraudulent, criminal acts, bodily injury and property damage claims, and contractual liabilities beyond those reasonably assumed under a professional services engagement. The applicant will promptly notify the insurer of any circumstance that may give rise to a claim.

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