Insurance E&O Proposal

INSURANCE E&O PROPOSAL

Applicant / Insured Information

Individual    Partnership    Corporation    LLC    Other:

Date of Birth (if Individual):    State of Incorporation/Registration (if applicable):

Business / Professional Information

Policy Details Requested

Policy Type:    Desired Limit (Per Claim/Aggregate):

Policy Period Requested: From to    Retroactive Date (if any):

Coverage Options

Please indicate coverage options requested:

Claims-made form    Occurrence form    Prior acts coverage

Defense costs included within limit    Defense costs in addition to limit

Coverage for disciplinary proceedings    Coverage for acts of subcontractors    Limited cyber/privacy liability (if available)

Claims History & Prior Acts

Has the applicant or any principal been involved in any claim, suit, disciplinary proceeding, or arbitration relating to professional services in the past 10 years?    Yes    No

Underwriting & Risk Management Questions

Does the applicant use written client agreements that limit liability and define scope of services?    Yes    No

Are background checks performed on employees providing professional services?    Yes    No

Exclusions & Limitations (Standard)

The following are examples of common exclusions that may apply to any policy issued: claims arising from fraudulent, criminal or intentionally wrongful acts; bodily injury or property damage; claims arising from regulated employee benefit plans (ERISA); asbestos, pollution, lead or mold; patent, trademark or trade secret infringement where professional advice is not the proximate cause; fines, penalties, and punitive or exemplary damages where unenforceable by law. Any modification or requested deletion of standard exclusions must be submitted in writing and is subject to underwriting review and additional premium.

Beneficiary Information

(For purposes of settlement or indemnity payments when designation is required by contract)

Documentation Checklist

Please check items attached to this proposal:

Resumes of principals    Sample client contracts    Financial statements

Prior policy declarations and loss runs (past 5 years)    Complete claims history documentation

Declaration and Authorization

The undersigned declares that to the best of their knowledge and belief the statements and particulars contained in this proposal are true, complete, and correctly recorded. The undersigned understands that this proposal and any attachments shall form the basis of any insurance policy issued and that any material misrepresentation or omission may be a basis for denial of coverage or rescission of the policy.

The applicant hereby authorizes the insurer and its representatives to make any inquiry in connection with this proposal as may be necessary, including obtaining loss history, credit or background information, and to disclose to and obtain from other insurers and service providers information relevant to the underwriting of this application.

Submission of this proposal does not bind coverage. No coverage will be in effect until a policy is issued and effective dates are specified by the insurer. Any changes to the information provided must be reported promptly in writing.

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