Specified Professions Professional Liability Application Form
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Specified Professions Professional Liability Product
SPECIFIED PROFESSIONS PROFESSIONAL LIABILITY APPLICATION
This is an application for a claims made policy. Please read your policy carefully.
SECTION I: BACKGROUND INFORMATION
1.
Name of Applicant: ________________________________________________________________________________________________________
2.
Address: _________________________________________________________________________________________________________________
City:________________________________________________________________________State: __________Zip:__________________________
Phone: _________________________Website Address: ________________________________Email Address: ___________________________
3.
Date established: ________________
(If business has been in operation less than 3 years, please provide the resume of a principal, partner or key employee.)
4.
Is the Applicant controlled, owned, affiliated or associated with any other firm, corporation or company?
Yes
No
If Yes, please provide names(s) and relationship(s);____________________________________________________________________________
5.
Does the Applicant have any subsidiaries?
Yes
No
If Yes, please list on a separate sheet and advise if coverage is to apply to them.
6.
Applicant is:
Corporation
Partnership
Individual
LLC
Non-Profit
SECTION II: ORGANIZATION OPERATIONS DETAILS
7.
Please describe in detail the professional services for which coverage is desired:
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
8.
(a) List total gross receipts derived from activities in Question #7 (start-ups please provide best estimates):
Gross Receipts
Last Year:
$ ____________________
Current Year (based on 12 months):
$ ____________________
Forecast for Next Year:
$ ____________________
(b) Please indicate the percent of receipts listed in 8a from foreign operations
(i.e. outside of the U.S. and its territories): __________________________________________
9.
Describe the 3 largest jobs or projects during the past 3 years
Name of Client
Services Provided
Gross Billings
________________________________________
________________________________________
_________________________________
________________________________________
________________________________________
_________________________________
________________________________________
________________________________________
_________________________________
10. Is the Applicant a licensed Professional (i.e. Lawyer, Accountant...)?
Yes
No
If Yes, advise type of licensed Professional: __________________________________________________________________________________
11. (a) Number of principals, partners, officers and professional employees directly engaged in providing
services to clients:_________________________________________________________________________________________________________
(b) Number of independent/subcontractors: __________________________________________________________________________________
12. Please answer the following questions regarding the use of independent contractors:
(a) The total percentage of work done by independent/subcontractors:
_________________%
(b) Do the independent/subcontractors work exclusively for the Applicant?
Yes
No
Professional
CONSA 1/08 - United States Liability Insurance Group
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