Insurance Errors & Omissions Renewal Form

Insurance Errors & Omissions Renewal Form

Applicant Name:   Business/DBA:

Policy Number:   Renewal Effective Date:

Applicant Contact & Identification

Entity and Professional Details

Entity Type: Individual Corporation LLC Partnership Other

Policy Renewal Details

Policy Type:   Coverage Limit: $

Deductible: $   Retroactive Date:

Policy Period From:   To:

Coverage Options

Defense costs within limit
Defense costs outside limit
Cyber/privacy breach enhancement
Regulatory/disciplinary proceeding coverage
Aggregate limit for entity coverage

Exclusions and Material Changes

Standard exclusions applicable to this renewal include but are not limited to: dishonest, fraudulent or criminal acts; bodily injury or property damage arising from non-professional services; punitive damages where unenforceable; claims arising from matters known prior to inception; contractual liability assumed beyond professional duty. The insurer reserves the right to amend exclusions subject to underwriting review.

Applicant certifies that there has been no material change in the nature of services provided, personnel, or risk exposures since the prior policy inception unless disclosed below. Material changes may affect insurability and premium.

I acknowledge and understand the exclusions listed above and accept responsibility to disclose any facts which may affect coverage.

Claims and Incidents (Past Five Years)

Any claims, suits, incidents, or circumstances that may give rise to a claim in the past five years?   No   Yes

Amount Paid: $   Reserve Amount: $   Status:

Amount Paid: $   Reserve Amount: $   Status:

Amount Paid: $   Reserve Amount: $   Status:

Documentation Checklist

Provide the following with this renewal submission: Most recent Declarations Page Loss run for prior five years Documentation of any professional complaints or disciplinary actions Representative contracts for services provided

Beneficiary / Payee for Return Premium

Premium Payment & Broker Information

Payment Method: Check Credit Card EFT/Bank Transfer

Declaration and Certification

The undersigned declares that the statements and particulars contained in this Renewal Form are true and complete to the best of their knowledge and belief. The undersigned acknowledges that any material misstatement, omission, or failure to disclose relevant facts may render the policy voidable or may result in denial of coverage for a related claim. The insurer is authorized to obtain loss history and claim information from prior insurers and to rely on the information provided herein for underwriting and rating this renewal.

Applicant further agrees to notify the insurer in writing of any material change in operations, personnel, services, or exposures that occurs prior to the effective date of any renewal policy. Coverage afforded by the renewed policy, if issued, is subject to the terms, conditions, limitations, endorsements and exclusions contained in the policy.

Applicant certification checked

Sign Now