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Commercial Insurance

Professional Liability Insurance

With a specialized profession, the greater the expectation. Such declaration is true in whatever field you are in. Be aware of your responsibilities. Secure yourself from probable lapses in executing your duties. You don't have to face lawsuits off guard. Protect the most important aspect of living — your profession. This insurance covers for negligence and omissions. If there are other coverages you would like to specify, let us know about it. We can make everything right for you.

Please check this box to receive a quote ASAP

Primary Insured

* Applicant Name

2.	Address:
	* Street Address 1:
	Street Address 2:
	* City:
	State:
	* Zip Code:
	* Phone:	( ) -
	* Email:

Professional Service(s):

P r i m a r y

Revenue ($)
Revenue (%)

S e c o n d a r y

Revenue ($)
Revenue (%)

T e r t i a r y

Revenue ($)
Revenue (%)

T O T A L

Revenue ($)

Revenue (%)

4.	Is the Applicant Firm controlled, owned, or associated with any other firm corporation or company?
	Yes No
	If Yes, please provide details here:

5.	Number of Years in Business:

6.	Average number of years of related professional experience for all Partners, Principals and Key Employees :

7.	What percentage of services are rendered under a written contract?

8.	Have any claim(s) been made against any proposed insured(s) during the past three years?
	Yes No
	If Yes, please provide details here:

9.	Have any Partners, Principals or Key Employees ever been the subject of disciplinary action by authorities as a result of their professional services?
	Yes No
	If Yes, please provide details here:

10.	Does any person or entity proposed for insurance have knowledge or information of any act, error or omission which might reasonably be expected to give rise to a claim under the proposed policy?
	Yes No
	If Yes, please provide details here:

11.	Has any similar insurance ever been declined or cancelled?
	Yes No
	If Yes, please provide details here:

12.	Is similar insurance currently in force?
	Yes No
	If Yes, please provide:
	Name of Carrier.
	If Other.
	Expiration Date
	Limit	$
	Deductible	$
	Premium	$
	Retroactive Date

13.	Please provide the number of years of continuous coverage


	It is agreed with respect to Questions #8, 9, and 10 above, that if such knowledge or information exists any claim or action arising therefrom is excluded from this proposed coverage.

Policy Coverage Details

1.	Limit of Liability (Each Wrongful Act/Aggregate)
3.	Deductible (Each Wrongful Act/Aggregate)

Other information you would like us to know:

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