Insurance Professional Liability Form

INSURANCE PROFESSIONAL LIABILITY FORM

Applicant / Insured Information

Policy Details Requested

Coverage form requested: Claims-made Occurrence Prior Acts Coverage

Retroactive date (if applicable):

Coverage Options & Endorsements

Select desired coverages and endorsements (check all that apply):

Professional Liability (Errors & Omissions)
Cyber / Privacy Liability
Defense Costs Outside Limit
Employment Practices Liability
Coverage for Subcontractors (subject to approval)
Extended Reporting Period Endorsement (ERP)

Exclusions and Acknowledgements

The policy, if issued, will contain exclusions customary to professional liability insurance, including but not limited to:

• Intentional criminal acts, fraudulent acts, and willful misconduct;
• Claims arising from bodily injury or property damage except where specifically included;
• Contractual liability beyond that which the insured would have in the absence of the contract, unless an insuring agreement expressly provides coverage;
• Claims arising from activities outside the scope of the declared professional services.

I acknowledge that I have read the typical exclusions and understand that specific exclusions will be set forth in the policy language. I request that any available endorsements or sublimits relevant to the insured's operations be quoted.

Professional Operations & Risk Management

Does the insured use written engagement letters or contracts with clients that limit liability or require indemnification? Yes No

Prior Claims, Circumstances and Regulatory Actions

Has any claim, suit, arbitration, or demand ever been made against the applicant or any principal, partner or officer? Yes No

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

Claims / Incident Notice (if applicable)

Documentation Checklist

Please attach or indicate documents provided:

Prior policy declarations / loss runs (past 5 years)
Sample client contracts / engagement letters
Key personnel resumes / CVs
Client list / significant projects
Other supporting documentation (describe below)

Beneficiary / Payee Designation

Provide the name and contact for the payee or beneficiary to receive any return of premium or policy proceeds where applicable.

Declarations, Authorizations and Certifications

By signing below the applicant certifies that the statements contained in this form and any attachments are true, complete and correct to the best of the applicant's knowledge. The applicant understands that coverage, if issued, will be issued subject to the policy terms, conditions, limitations and exclusions. The applicant acknowledges that the insurer will rely upon the representations made in this form in determining eligibility and premium.

The applicant authorizes any person or entity to release to the insurer or its representatives any records or information requested in connection with the underwriting or investigation of this application, including prior loss information, disciplinary proceedings and relevant contracts. This authorization shall survive the execution of this application.

The applicant acknowledges that failure to disclose material facts or making materially false statements may result in denial of coverage, rescission of the policy, or denial of claims. The applicant further acknowledges that coverage for claims arising from known circumstances must be disclosed and may be excluded by the insurer.

Submission of this form does not bind coverage. No coverage is in effect until a policy is issued and the required premium is paid. Any quotation of terms, conditions or premium is subject to the insurer's underwriting review and acceptance.

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