Specified Professions Professional Liability Application Form Page 3
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423. Is similar professional liability insurance currently in force?
Yes
No
Name of Carrier
Limit
Retroactive Date (if any)
Deductible
Premium
Policy Period
______________________________ ________________ _______________________ _____________ ________________ ________________
Length of time coverage has continuously been in force: _____________________________________________________________________
SECTION V: BUSINESSOWNERS PACKAGE INSURANCE
24. Has the Applicant had any General Liability claims paid, reserved or pending in the last 5 years?
Yes
No
If Yes, please provide details. _______________________________________________________________________________________________
_________________________________________________________________________________________________________________________
25. Additional Insured(s) to be included on General Liability:
Name
Relationship to Applicant
Address
1. ______________________________________
________________________________________
_________________________________
_________________________________
2. ______________________________________
________________________________________
_________________________________
_________________________________
3. ______________________________________
________________________________________
_________________________________
_________________________________
26. Personal Property Limit, including computer hardware (at 80% coinsurance/replacement cost): _____________________________________
27. Building Characteristics
a.
Are functioning burglar alarms present?
Yes
No
b.
Is all electrical wiring connected to functional and operational circuit breakers?
Yes
No
c.
Are there functioning smoke and heat detectors in all units and/or occupancies?
Yes
No
d.
Is aluminum wiring present in the building?
Yes
No
28. Property Protection Class (1-10): ______________________________
29. Building Construction (please check one):
Frame - Bldg. is made from a wood frame (2x4’s/veneers).
Joisted Masonry - Outside walls are constructed with bricks/cinder blocks. Roof is made of wood.
Masonry Non-Combustible - Same as Joisted Masonry, except roof is steel.
Fire Resistive - Structural steel framing, reinforced concrete outside/load bearing walls.
30. Has the Applicant had any Property claims paid, reserved or pending in the last 5 years?
Yes
No
If Yes, please provide details. _______________________________________________________________________________________________
_________________________________________________________________________________________________________________________
SECTION VI: REQUIRED INFORMATION
A.
USLI Application.
B.
Copy of resumes on technical and key personnel (for select classes)
C. Supplemental Application (for select classes)
Virginia Notice: Statements in the application shall be deemed the insured’s representations. A statement made in the application or in any
affidavit made before or after a loss under the policy will not be deemed material or invalidate coverage unless it is clearly proven that such
statement was material to the risk when assumed and was untrue.
Minnesota Notice: The clause “and/or authorization or agreement to bind the insurance.” is replaced with “Authorization or agreement to bind
the insurance may be withdrawn or modified based on changes to the information contained in this application prior to the effective date of the
insurance applied for that may render inaccurate, untrue or incomplete any statement made with a minimum of 10 days notice given to the
insured prior to the effective date of cancellation when the contract has been in effect for less than 90 days or is being canceled for
nonpayment of premium.
Professional
CONSA 1/08 - United States Liability Insurance Group
page 3 of 4
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