Professional Liability EZ-App

Step 1 of 2: Submit

For fast service on your commercial accounts complete the form below and click "Continue". Your submission will be electronically delivered to the next available Commercial Lines Underwriter.

Producer Information

Producer Name: Producer Code: Producer Phone Number: Producer Fax Number: Email Address: Agency Contact Name:

Insured Information:

Insured Name: Insured Address: Insured Website Address:

Number of Employees:

Full-time: Part-time: Seasonal: Total: Date Established:

Describe in detail all the professional services and indicate the percentage of gross revenues derived from each activity. Estimated Annual Revenue: $ Annual Gross Revenues for the last three years:

Were more than fifty percent of the Applicant's revenue derived from one client? Select one Yes No

If Yes, specify client and description of services rendered:

Does the Applicant utilize the services of independent contractors or sub-consultants: Select one Yes No

If Yes, indicate percentage of billings and whether a certificate of Professional Liability is required of each:

Does the Applicant build, service, repair, install, manufacture or fabricate anything? Select one Yes No

Does the Applicant sell any product other than computer software? Select One Yes No

If Yes, please describe:

Does the Applicant carry General Liability Insurance? Select one Yes No

If Yes, Provide: Insurer: & Limits:

Is a Professional Liability (E&O) insurance currently in force? Select one Yes No

If Yes, provide information regarding coverage during the past five (5) years: Company, Exp. Date, Limits and Premium. Retroactive Date of Current Policy:

During the last five years, have here been any professional liability claims against the Applicant proposed for this insurance? (If Yes, please provide loss runs) Select One Yes (Please provide loss runs) No

Is (are) any person(s) or entity(ies) aware of any fact, circumstance or situation which might afford grounds for any claim, such as would fall under the proposed insurance? Select one Yes No

If Yes, please provide details.

Has any insurer cancelled, rescinded, non-renewed or declined any similar insurance for the Applicant proposed for this insurance in the last five years? Select one Yes (If Yes, please attach a copy of such insurer's notice) No

During the past 5 years has the Applicant been named as a Defendant or Plaintiff in a lawsuit? Select one Yes No

If Yes, please supply full details. Limits of Liability Desired: $ Deductible Desired: $