Specified Professions Professional Liability Application Form Page 2
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4(c) Do the independent/subcontractors provide the same services as the applicant?
Yes
No
If No, please explain: __________________________________________________________________________________________________
(d) Are all independent/subcontractors required to carry errors and omissions insurance?
Yes
No
(e) Does the Applicant desire to provide coverage for independent/subcontractors (including them as named
insured(s) on the policy) while working on the Applicant's behalf?
Yes
No
13. Please provide the following:
Name of Partners,
Professional
# of Years
Key Employees and Independent/
Qualifications/
in Practice
Subcontractors
Designations
_________________________________________
_____________________________________________
_____________________________
_________________________________________
_____________________________________________
_____________________________
_________________________________________
_____________________________________________
_____________________________
14. Does any director, officer, employee, partner or independent/subcontractor of the Applicant serve as an officer
or on the Board of Directors of any client or own any financial or equity interest in any client of the Applicant?
Yes
No
If Yes, attach an explanation. _______________________________________________________________________________________________
15. What do you see as your potential exposure to a professional liability claim? _____________________________________________________
_________________________________________________________________________________________________________________________
16. Does the Applicant use a written contract or letter of engagement with clients?
In all cases
Sometimes
Never
17. Additional Insured(s) to be included for Errors and Omissions (list name, address and relationship to Applicant): ______________________
_________________________________________________________________________________________________________________________
18. Has any prospective insured ever had their license revoked or suspended or been fined or disciplined in any
way or been the subject of any investigation by any regulating body related to their profession?
Yes
No
If Yes, attach an explanation. _______________________________________________________________________________________________
SECTION III: CLAIMS INFORMATION
Do not complete this section if this is an application for a renewal policy at the same limit of liability with one of the USLI companies.
19. Have you initiated litigation against any of your clients in the past 5 years?
Yes
No
(If Yes, advise how many times you have initiated litigation in the past 5 years along with details for each.) ___________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
20. During the past 5 years, has any claim been made or suit brought against the Applicant, its predecessor(s) in business, or
any of its present or former owners, partners, officers, directors, employees or independent contractors?
Yes
No
(If Yes, please provide details on a separate supplemental claim application.)
21. Is any owner, partner, officer, director, employee or independent contractor aware of any circumstance, allegation,
contention, or incident which may result in a claim being made against the Applicant, its predecessor(s) in business,
or any of its present or former partners, owners, officers, directors, employees or independent contractors?
Yes
No
(If Yes, please provide details on a separate supplemental claim application.)
SECTION IV: PROFESSIONAL LIABILITY INSURANCE COVERAGE
22. Has any Policy or Application for professional liability insurance on your behalf or on the behalf of any of your
principals, officers, employees, independent contractors, or on behalf of any predecessor(s) in business ever
been declined, cancelled or renewal refused? Not applicable in Missouri .
Yes
No
If Yes, advise details: ______________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Professional
CONSA1/08 - United States Liability Insurance Group
page 2 of 4
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