Insurance Professional Liability Application

INSURANCE PROFESSIONAL LIABILITY APPLICATION

Applicant / Insured Information

Policy Details

Coverage Form Requested: Claims-Made Occurrence

Coverage Options and Limits

Select optional coverages requested:

Exclusions and Acknowledgements

The policy to be issued will contain standard professional liability exclusions including, without limitation, claims arising from:

• Deliberate fraudulent acts, criminal acts or intentional non-compliance with statutes;
• Bodily injury or property damage except to the extent provided by endorsement;
• Contractual liability beyond limits agreed by endorsement;
• Claims arising from services rendered outside the scope of the declared profession or outside declared jurisdictions;
• Prior knowledge of facts or circumstances that could reasonably give rise to a claim unless covered by prior acts endorsement.

Applicant acknowledges that full particulars of the exclusions will be set forth in the policy form and that no coverage will attach for excluded matters unless expressly provided by endorsement. Applicant confirms review of these exclusion types: I acknowledge

Claims, Circumstances and Disciplinary History

In the past ten (10) years, has any claim or suit been made against the applicant, or does the applicant have knowledge of any circumstance that could give rise to a claim?

If yes, provide details for each matter (attach additional pages if necessary):

Provide up to two additional matters if applicable:

Has the applicant ever been the subject of disciplinary or regulatory action, or is any such action pending?

Risk Management Practices

Indicate which of the following the applicant employs routinely:

Beneficiary / Payee Information

If refunds or return premiums are to be paid to a party other than the named insured, identify the payee below.

Declarations and Certifications

The undersigned applicant declares that the statements and particulars in this application are true and complete to the best of the applicant's knowledge and are offered as the basis for underwriting. The applicant understands and agrees that:

1. Any policy issued will be issued in reliance upon the truth of the statements made in this application and in any attachments; material misrepresentation, omission or concealment may result in rescission, denial of coverage or refusal of claims.
2. The completion of this application does not bind the company to issue, nor the applicant to accept, insurance; any coverage will be subject to the terms, conditions, limitations and exclusions of the policy issued.
3. The insurer may, to the extent permitted by law, undertake inquiries to verify the information provided and the applicant consents to the release of claim and underwriting information to the insurer and its representatives.
4. Notice of claim or suit must be given as required by the policy and failure to comply with notice provisions may affect coverage.

By signing below, the applicant certifies that all material information has been provided and authorizes the insurer to obtain underwriting and claim history from current and prior insurers and other legitimate sources.

Attachments Checklist

Please attach copies of the following, as applicable (check items included):

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