Insurance E&O Questions Form

INSURANCE E&O QUESTIONS FORM

Applicant / Insured Information

Applicant Name:

Policy Details Requested

Policy Type (select all that apply): Professional Liability (E&O) Cyber Liability (optional) Media/Technology Liability

Requested Policy Period: From to .

Operations and Professional Exposure

Describe the primary professional services offered by the applicant (attach scope of services or standard client agreement):

Average annual gross revenue from professional services:

Claims, Circumstances and Prior Acts

In the past five (5) years, has any claim, suit, arbitration, demand for damages, or notice of potential claim been made against the applicant or any of its principals? Yes No

If Yes, provide date(s), brief description, amount paid/reserved and current status:

Has any professional license, registration or certification been suspended, revoked, or subject to disciplinary action? Yes No

Has any E&O or professional liability policy on behalf of the applicant ever been cancelled, non‑renewed or declined? Yes No

Coverage Options and Retroactive Date

Coverage is requested on a Claims‑Made basis unless otherwise agreed. Retroactive Date (if requested):

Defense Outside the Limit of Liability: Yes No

Exclusions and Exceptions

Standard exclusions may include fraud, intentional misconduct, bodily injury and property damage (where other coverages apply), criminal acts, warranties and prior acts not listed. Are there any circumstances, clients, contracts, or transactions that you request to be excluded from coverage? Yes No

Beneficiary Designation (If Applicable)

List beneficiary for any return premium or claim proceeds payable to the applicant's estate or designate payee. Provide name, relationship, and percentage allocation.

Documentation Checklist (Attach as applicable)

Loss runs / claims history (past 5 years) Prior E&O policy declarations Typical client contract / engagement letter Resumes of principals / key professionals

Declaration and Certification

The undersigned declares that the information contained in this form and in any attachments is true, accurate and complete to the best of the undersigned's knowledge. The undersigned understands that this form is a part of the application for professional liability insurance and that any material misrepresentation, omission or concealment of fact may be grounds for denial of coverage or rescission of the policy, to the extent permitted by law. The undersigned further agrees to notify the insurer in writing as soon as practicable of any claim or circumstance that may give rise to a claim during the policy period or extended reporting period.

By signing below, the undersigned authorizes the insurer and its authorized representatives to make inquiries and obtain records, including claim histories and insurance regulatory records, necessary to evaluate this application. The undersigned acknowledges that acceptance of this application by the insurer is subject to underwriting review and that coverage, limits and terms will be set forth in the policy documents.

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