Insurance E&O Statement

INSURANCE E&O STATEMENT

Insured Information

Date of Birth:    Professional Licenses / Reg. #:

Policy Details

Policy Period From:    To:    Retroactive Date (if applicable):

Coverage Details

Type of Coverage (check all that apply):

Professional liability for errors and omissions in the performance of professional services
Network security / privacy liability
Defense costs within limits
Defense costs outside limits
Claims-made basis
Occurrence basis

Exclusions & Special Terms

The following exclusions and conditions apply. Check those included in the policy and provide additional detail where requested.

Criminal acts, fraud or intentional dishonest acts
Bodily injury or property damage (not covered under E&O)
Contractual liability except where liability would have existed absent the contract
Punitive or exemplary damages where unenforceable by law
Claims or circumstances known prior to inception
Insolvency of insured or bankruptcy carve-outs
Other exclusions (describe below)

Claims History

Has the insured, any partner, officer, director, or predecessor entity had any claim, suit, demand, or notice of circumstance that could give rise to a claim in the past five years?    Yes    No

If yes, provide details for each matter. Attach additional pages if necessary.

Documentation Checklist

Please indicate documents attached (if applicable):

Loss reports / claim forms
Court pleadings or settlement agreements
Relevant correspondence (demand letters, notices)
Contracts or engagement letters related to claim
Other supporting documentation (describe below)

Beneficiary Designation

For any policy proceeds payable to the insured's estate or beneficiary in the event of death, designate primary beneficiaries below.

Declaration and Certification

I certify that the information provided in this Insurance E&O Statement is true, accurate and complete to the best of my knowledge. I understand that any material misrepresentation, false statement, omission, or concealment of fact may be grounds for denial of coverage or rescission of the policy and may be subject to civil or criminal penalties under applicable law.

I acknowledge my continuing obligation to report to the insurer any claim, suit, demand, or circumstance that could reasonably be expected to give rise to a claim under any policy for which this statement is provided. I authorize the release of claim and underwriting information to and from any prior or current insurers for purposes of underwriting, claims handling, and coverage determination.

I understand that the insurer may rely upon this statement in determining eligibility for coverage and in establishing policy terms, limits, and premiums.

Sign Now