Insurance PFA Application

INSURANCE PFA APPLICATION

Applicant / Insured Information

Applicant Name:

Date of Birth:    Social Security / Tax ID:

Business / Professional Information

Business Name (if applicable):

Professional Title / License:    License Number(s):

Policy Details Requested

Policy Type:

Desired Coverage Limit: $    Requested Deductible: $

Annual Premium Quoted: $

Policy Period From: to

Retroactive Date (if applicable):

Coverage Options (select all that apply)

Errors & Omissions (E&O) coverage
Fiduciary Liability coverage
Cyber Liability coverage
Employee Dishonesty / Crime coverage
Fidelity Bonds / Surety Bonds

Prior Insurance and Claims History

Have you ever had a professional liability or similar policy declined, cancelled, or non-renewed?    Yes    No

During the past five (5) years, have any claims, suits, or incidents been made against you or your firm that could give rise to a claim under the requested coverage?    Yes    No

Exclusions and Limitations (Acknowledgement)

The following are material exclusions typically applied to this coverage. Applicant acknowledges that coverage will not apply to:

1. Intentional fraudulent acts, criminal acts or willful violations of law by the insured; unauthorized trading or misappropriation of client assets; and professional services performed while impaired by drugs or alcohol.
2. Claims arising from bodily injury, property damage, or punitive damages except as may be required by law or specifically endorsed.
3. Liability assumed under contract beyond the scope of professional services, except where liability would have existed in the absence of such contract.
4. Prior acts not disclosed or material facts omitted at the time of application.

I acknowledge I have read the exclusions above and understand coverage limitations. Acknowledged

Beneficiary Designation (If Applicable)

Primary Beneficiary Name:

Relationship to Applicant:    Share Percentage:

Secondary Relationship:    Secondary Share Percentage:

Declarations, Authorization and Certification

The undersigned applicant certifies that the statements and information contained in this application are true and complete to the best of the applicant's knowledge and belief. Misrepresentation, omission, or concealment of material facts may be grounds for denial of coverage or retroactive rescission of the policy.

Authorization: The applicant authorizes the insurer, its agents, and service providers to obtain and verify any information reasonably necessary for underwriting and claims handling, including but not limited to professional credentials, claims records, loss history, and disciplinary actions. A photocopy or electronic copy of this authorization shall be as valid as the original.

Fraud Notice: Any person who knowingly and with intent to defraud submits an application containing false information or conceals information for the purpose of misleading the insurer may be guilty of insurance fraud and subject to civil and criminal penalties under applicable law.

Supplemental Attachments

Please attach the following documentation as applicable (check when attached):
Professional resume / CV
Recent financial statements
Client engagement letters / contracts
Prior policy declarations / loss runs

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