LIBERTY INSURANCE UNDERWRITERS INC. (A Stock Insurance Company, hereinafter the Company ) 55 Water Street, 23rd Floor, New York, NY 10041
|
|
- Gary Cross
- 6 years ago
- Views:
Transcription
1 Toll-free number: LIBERTY INSURANCE UNDERWRITERS INC. (A Stock Insurance Company, hereinafter the Company ) 55 Water Street, 23rd Floor, New York, NY RENEWAL APPLICATION UNLESS OTHERWISE ENDORSED, CLAIM EXPENSES SHALL BE APPLIED TO, AND ACT AS A REDUCTION OF, UP TO 100 OF THE DEDUCTIBLE, AND UP TO 100 OF THE LIMITS OF INSURANCE. THIS COULD THEN RESULT IN SUCH DEDUCTIBLE AND SUCH LIMIT OF INSURANCE BECOMING COMPLETELY EXHAUSTED BY THE PAYMENT OF CLAIM EXPENSES. THE COMPANY SHALL NOT BE LIABLE FOR ANY CLAIM EXPENSES OR DAMAGES UNTIL AFTER THE EXHAUSTION OF THE DEDUCTIBLE, AND THE COMPANY SHALL NOT BE LIABLE FOR ANY CLAIM EXPENSES OR DAMAGES AFTER THE EXHAUSTION OF THE LIMITS OF INSURANCE. THIS POLICY ONLY COVERS CLAIMS ACTUALLY MADE AGAINST AN INSURED UNDER THE POLICY WHILE THE POLICY REMAINS IN EFFECT. CLAIMS MAY BE REPORTED, HOWEVER, DURING THE CLAIMS MADE RELATIONSHIP OR DURING THE AUTOMATIC EXTENDED CLAIM REPORTING PERIOD OR ANY ADDITIONAL REPORTING PERIOD YOU MAY PURCHASE. ALL COVERAGE UNDER THIS POLICY CEASES UPON TERMINATION OF THE POLICY, EXCEPT FOR THE AUTOMATIC EXTENDED REPORTING PERIOD COVERAGE, UNLESS THE INSURED PURCHASES ADDITIONAL EXTENDED REPORTING PERIOD COVERAGE. THIS POLICY PROVIDES NO COVERAGE FOR CLAIMS ARISING OUT OF INCIDENTS, SITUATIONS OR ACTS OR OMISSIONS WHICH TOOK PLACE PRIOR TO THE PRIOR ACTS DATE, IF ANY, STATED IN POLICY. DURING THE FIRST SEVERAL YEARS OF THE CLAIMS-MADE RELATIONSHIP, CLAIMS-MADE RATES ARE COMPARATIVELY LOWER THAN OCCURRENCE RATES. SUBSTANTIAL ANNUAL PREMIUM INCREASES CAN BE EXPECTED, INDEPENDENT OF OVERALL RATE LEVEL INCREASES, UNTIL THE CLAIMS-MADE RELATIONSHIP REACHES MATURITY. THE FOLLOWING EXTENDED REPORTING PERIODS ARE AVAILABLE UPON TERMINATION OF COVERAGE AND THE NAMED INSURED SHALL BE CHARGED A PERCENTAGE OF THE POLICY S PREMIUM, USING RATES IN EFFECT ON THE EFFECTIVE DATE OF THE POLICY. POTENTIAL COVERAGE GAPS MAY ARISE UPON EXPIRATION OF EXTENDED REPORTING PERIOD COVERAGE. Extended Reporting Period 60-day Automatic Extended Reporting Period 1 Year Optional Extended Reporting Period 3 Year Optional Extended Reporting Period 5 Year Optional Extended Reporting Period 1 Maximum Percentage of Annual Premium Additional Premium
2 Toll-free number: A. FIRM INFORMATION Firm Name: Primary Office Address: Contact Person: Firm 1. City: Title: Firm Phone: St: Zip: Contact Phone: Does your firm or any owner, partner or officer render services or conduct any business activities under any other name? If there are changes from previous year, complete the SEPARATE ENTITY SUPPLEMENT on page S-1 Please complete the remainder of the application with respect to the firm and all entities listed previously and currently on the Separate Entity Supplement. Wherever the words firm affiliates are used, they will be deemed to include these entities Please indicate the number of personnel for your firm and firm affiliates: CPA Owners, Partners & Officers n CPA Owners, Partners & Officers Employed CPAs (other than identified above) Other Accounting or Tax Professionals Consulting Professionals Support Staff ( all others) Total Firm Personnel Gross annual revenue for the firm and firm affiliates on an accrual basis: Last Fiscal Year Estimated Current Fiscal Year FYE: FYE: $ $ If estimated current fiscal year revenues are more than +/- 15 from the last fiscal year revenues, provide an explanation on a separate sheet. B. SCOPE OF PRACTICE 4. Provide the percentage of gross annual revenue derived from the following areas of practice. Total of all items must equal 100. Are annual engagement Are annual engagement letters used? letters used? A. Business Tax Services L. Other Attest/Assurance Services B. Estate Tax Services (Please describe) C. Individual Tax Services M. Business Planning (Please describe) D. Accounting/Bookkeeping N. Business Valuation E. Compilation O. Litigation Consulting F. Review P. n-trustee Fiduciary or G. Audit: Publicly held clients Administrative Responsibility- ERISA, complete the Public Audit Supplement Pension & Benefit Plans, ESOPS, H. Audit: n-public clients Insurance Co s, Hedge Funds, other complete the n- Public Audit Investment Co s. (Please describe and include Supplement client list with asset size and number of 2
3 Toll-free number: I. Agreed Upon Procedures J. Projections/Forecasts participants) Q. Information Technology K. Financial Planning and Investment Advisory Services R Other Consulting (Please describe) Complete the Financial Planning Supplement 5. Estimated total number of clients for last fiscal year: 6. Percentage of revenue from largest client: Client industry: TOTAL ADDS TO 100 Client name: Services rendered by firm: C. CHANGES TO YOUR PRACTICE Answer only when there is new information that was not provided on previous years applications. 7. Have there been any changes in the organization or structure of the firm or addition of a new client industry or scope of practice? If so, complete the appropriate Supplement. Performed audit, review, attestation or consulting services to publicly-held companies, their subsidiaries or their employee benefit plans? If yes, complete the PUBLIC COMPANY SUPPLEMENT on page S Served as a trustee, co-trustee, executor, administrator or personal representative? If yes, complete the TRUSTEE & ESTATE SUPPLEMENT on page S Controlled or disbursed client funds (including payroll)? If yes, complete the FUNDS CONTROLLED SUPPLEMENT on page S Performed services or consented to the use of your work product in connection with public or private offerings of securities, real estate or other investments? If yes, complete the PUBLIC & PRIVATE OFFERINGS SUPPLEMENT on page S rendered services, other than tax, for any client in which firm personnel, or the spouse of firm personnel, owned or received an equity interest or served as an officer, director, partner, manager or other member of a client's governing body? If yes, complete the OUTSIDE INTEREST SUPPLEMENT on page S arranged debt or equity financing or acted as a business broker? If yes, provide the name of each client, the services rendered, and the amount and form of compensation paid to your firm, firm affiliates or their personnel on a separate sheet. Within the past year, has your firm, firm affiliates or their personnel:. Obtain a professional license other than a CPA license? If yes, provide person's name, type of license, revenues from activity, professional liability insurer, limits of liability and expiration date of policy on a separate sheet. 9. 3
4 Toll-free number: rendered services, other than tax, for a business client that subsequently declared or filed bankruptcy, defaulted on a debt obligation or became insolvent? If yes, provide the following: Name of client and client industry 4 Type of services you rendered and dates of your services Type of audit opinion Going concern reference? Date of bankruptcy, insolvency or default
5 Toll-free number: D. QUALITY CONTROLS 16. Within the past year, has your firm or firm affiliates sued to collect fees, including small claims court? If yes, provide on a separate sheet the amount, status, reason for suit and procedures for monitoring outstanding fees. 17. Within the past three years, has your firm undergone a peer or quality review offered by the AICPA or any state CPA Society? Opinion rendered: Unqualified/Unmodified Qualified/Modified Other Date issued: If there was a letter of comments or the opinion was Qualified, Modified or Other, please attach a copy of the Peer Review Report as well as the Letter of Comments and the firm's Letter of Response and the same data from the firm's prior peer review. If your firm has NOT undergone peer review and provides compilation, review and/or audit services, please indicate the anticipated date of review. If no review planned please explain why. E. CLAIMS INFORMATION 1. After inquiry of all owners, partners, officers and professionals of the firm and firm affiliates, within the past year have any past or present personnel: (a) been the subject of any regulatory or disciplinary investigation or inquiry (both formal and informal) or suspended from practice? (b) charged or plead guilty to, or indicted on a criminal charge? (c) become aware of any act, omission, circumstance or fee dispute which might be expected to be the basis of a claim or suit? (d) received updated information on any claim or potential claim reported to a carrier other than the Company? If yes to ANY, complete CLAIM/INCIDENT SUPPLEMENT on page S-9. Remember, any claim or incident should be reported to the Company within the policy period. NOTICE 1. Neither the responses to this application nor any attachments thereto constitute a submission of a claim or notice of circumstances, occurrences or potential claims under any existing insurance policy. r does any such responses indicate or imply that any claim, act or omission disclosed will be covered by this policy. 2. Applicant's failure to report to its current insurance company any claim made against it during the current policy term, or act, omission or circumstance which Applicant is aware of which may give rise to a claim before the expiration of the current policy may create a lack of coverage F. COVERAGE SELECTION Limits of Liability: $ Deductible: $ (Indicate your desired coverage selection) Per Claim or Annual Aggregate G. OPTIONAL COVERAGES If you are interested in a quotation, check the box by the desired coverage option and complete the appropriate supplement. Quotations are subject to underwriting approval. 27. Registered Representative Coverage. Complete the Financial Planning and Investment Advisory Services Supplement on page S Life Insurance Agent Coverage. Complete Question 10 of the the Financial Planning and Investment Advisory Services Supplement on page S Employee Dishonesty Coverage. Complete the Funds Controlled Supplement on page S Outside Organization Directors & Officers Defense Coverage. Complete the D&O Defense Supplement on page S-10. 5
6 Toll-free number: Employment Practices Liability Defense Coverage. Complete the Employment Practices Defense Supplement on page SAccountants Privacy and Network Security Risk Coverage. Complete the Privacy and Network Security Risk Supplement on page S-11. ADDITIONAL INFORMATION Attach separate sheets with all additional information, as necessary. Please indicate the question number and date when providing additional information. False Information (All States Except AL, AR, CO, DC, FL, HI, KY, LA, ME, MD, NJ, NM, NY, OH, OK, OR, PA, RI, TN, VA, VT, WA, WV): Any person who, knowingly and with the intent to defraud any insurance company or other person, files an application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime. ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof. ARKANSAS, LOUISIANA, RHODE ISLAND AND WEST VIRGINIA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claiming with regard to a settlement or award payable for insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies. DISTRICT OF COLUMBIA APPLICANTS: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer of any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony of the third degree. HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both. KANSAS APPLICANTS: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act. 6
7 Toll-free number: KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information containing any fact material thereto commits a fraudulent insurance act, which is a crime. MAINE, TENNESSEE AND VIRGINIA, AND WASHINGTON APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. NEW MEXICO APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and maybe subject to civil fines and criminal penalties. NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. OREGON APPLICANTS: Any person who knowingly and with the intent to defraud any insurance company or other person, files an application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any fact material thereto, may be guilty and subject to prosecution for insurance fraud. PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. VERMONT APPLICANTS: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law. THE COMPLETION OF THIS APPLICATION OR THE ATTACHED SUPPLEMENTS, OR TENDERING OF PREMIUM DOES NOT BIND COVERAGE. THIS APPLICATION IS SUBJECT TO THE UNDERWRITING RULES OF THE INSURANCE COMPANY. 7
8 Toll-free number: SIGNATURE The undersigned proprietor, authorized partner of the partnership, or authorized stockholder of the corporation represents that the following statements are understood and agreed to by the applicant: By signing this application, the undersigned represents that he or she has made inquiries of all Firm members as appropriate and that all Firm members are bound by the representations made on this application, any supplemental application, and any supplemental data and documents provided. Signing this application or tendering premium does not bind the applicant or the company to issue insurance coverage, but it is agreed that this application shall be the basis of the contract should a policy be produced. After inquiry of all stockholders, partners and employees, the undersigned is not currently aware of any act, error, omission, incident, circumstance, dispute, fee dispute or employee problem, which could reasonably be expected to be the basis of a claim being made against the Firm, its predecessors or any partner, stockholder or employee, that has not been reported to another insurer. It is understood and agreed that any claim emanating from such knowledge or information shall be excluded from coverage under the proposed policy. IMPORTANT: The Company intends to rely upon your answers to questions in this application and any attached supplements in reaching its decision to offer coverage and/or to offer coverage excluding any described activities. Inaccurate responses to inquiries may result in a loss of coverage for activities and/or a decision by LIU to rescind the entire policy. Your signature below acknowledges your understanding of this notice. Must be signed by a person who has the authority to sign on behalf of and to bind the Applicant, all firms and individuals requesting insurance through this application. Signature of Applicant Title Date Print Name: Agent, broker or producer of this application for coverage (if applicable): Name: (Please Print) Company: Signature: Date:
Legalis Consilium EMPLOYMENT DATES
Legalis Consilium NEW LAWYER SUPPLEMENT FOR LAWYERS PROFESSIONAL LIABILITY INSURANCE THIS APPLICATION IS FOR A CLAIMS MADE AND REPORTED INSURANCE POLICY 1. Firm: Policy Number: 2. Complete the following
More informationInstructions for Completing this Application GENERAL INFORMATION. 1. Name of Applicant: 2. Business Address:
This completed document should be submitted to: ALTRU, LLC 3975 Erie Avenue Cincinnati, OH 45208 T: 800-529-8850 www.altru.com OLD REPUBLIC INSURANCE COMPANY MISCELLANEOUS PROFESSIONAL LIABILITY APPLICATION
More informationCAMICO MUTUAL INSURANCE COMPANY SMALL FIRM ACCOUNTANTS PROFESSIONAL LIABILITY APPLICATION QUALIFICATION CHECKLIST
CAMICO MUTUAL INSURANCE COMPANY SMALL FIRM ACCOUNTANTS PROFESSIONAL LIABILITY APPLICATION QUALIFICATION CHECKLIST QUALIFICATION CHECKLIST PLEASE CHECK THE STATEMENTS APPLICABLE TO YOUR FIRM, ITS PREDECESSORS,
More informationACE Privacy Protection Privacy & Network Liability Insurance Program Renewal Application
ACE Privacy Protection Privacy & Network Liability Insurance Program Renewal Application NOTICE The Policy for which you are applying is written on a claims made and reported basis. Only claims first made
More informationAPPRAISAL MANAGEMENT COMPANY PROFESSIONAL LIABILITY APPLICATION
Lexington Insurance Company Administrative Offices: 99 High Street, Floor 23 Boston, Massachusetts 02110-2378 SEND APPLICATIONS AND INQUIRIES TO: 1438-F West Main Street, Ephrata, PA 17522-1345 800.640.7601;
More informationPRIVATE COMPANY SUPPLEMENTAL CLAIM FORM
PRIVATE COMPANY SUPPLEMENTAL CLAIM FORM Name of Insurance Company to which application is made INSTRUCTIONS: This form is to be completed by an Applicant who has been involved in any claim or suit during
More informationEMPLOYEE STOCK OWNERSHIP PLAN RENEWAL QUESTIONNAIRE
EMPLOYEE STOCK OWNERSHIP PLAN RENEWAL QUESTIONNAIRE Name of Insurance Company to which application is made COMPLETION OF THIS QUESTIONNAIRE IS REQUIRED WHEN SEEKING COVERAGE FOR A STANDALONE EMPLOYEE STOCK
More informationAPPLICATION FOR FIDUCIARY LIABILITY COVERAGE PART
APPLICATION FOR FIDUCIARY LIABILITY COVERAGE PART THIS APPLICATION IS FOR A CLAIMS-MADE POLICY. "CLAIMS" MUST BE FIRST MADE AGAINST AN "INSURED PERSON" DURING THE "POLICY PERIOD" OR ANY APPLICABLE EXTENDED
More informationIRONSHORE INSURANCE INC. One State Street Plaza, 8 th Floor New York, NY Tel: Toll Free: (877) IRON-411
IRONSHORE INSURANCE INC. One State Street Plaza, 8 th Floor New York, NY 10004 Tel: 646-826-6600 Toll Free: (877) IRON-411 CONSULTANTS PROFESSIONAL LIABILITY INSURANCE APPLICATION THE APPLICANT IS APPLYING
More informationTHE HARTFORD PROFESSIONAL LIABILITY INSURANCE POLICY SM THIRD PARTY ADMINISTRATORS SUPPLEMENTAL APPLICATION
THE HARTFORD PROFESSIONAL LIABILITY INSURANCE POLICY SM THIRD PARTY ADMINISTRATORS SUPPLEMENTAL APPLICATION This is a supplement to an application for a CLAIMS MADE and REPORTED Policy. It is to be used
More informationTHE HARTFORD PROFESSIONAL LIABILITY INSURANCE POLICY SM TRUSTEE SUPPLEMENTAL APPLICATION
THE HARTFORD PROFESSIONAL LIABILITY INSURANCE POLICY SM TRUSTEE SUPPLEMENTAL APPLICATION This is a supplement to an application for a CLAIMS MADE and REPORTED Policy. It is to be used solely in conjunction
More informationZURICH AMERICAN INSURANCE COMPANY BLANKET ACCIDENT INSURANCE POLICY PROOF OF COVERED LOSS FORM Mail claims to: INSTRUCTIONS
ZURICH AMERICAN INSURANCE COMPANY BLANKET ACCIDENT INSURANCE POLICY PROOF OF COVERED LOSS FORM Mail claims to: Administrative Concepts, Inc. 994 Old Eagle School Road Suite 1005 Wayne, PA 19087-1802 www.visit-aci.com
More informationTouring Entertainers Application
About This Program This application is used to insure touring musical groups, entertainers and performers, as well as house bands and cover bands. Required Documents The following documents are required
More informationNON-PROFIT ORGANIZATION MANAGEMENT LIABILITY RENEWAL APPLICATION
NON-PROFIT ORGANIZATION MANAGEMENT LIABILITY RENEWAL APPLICATION NOTICE: THIS IS A CLAIMS MADE AND REPORTED POLICY THAT APPLIES ONLY TO THOSE CLAIMS FIRST MADE AGAINST THE INSURED DURING THE POLICY PERIOD
More informationCONSTABLE PROFESSIONAL LIABILITY APPLICATION
CONSTABLE PROFESSIONAL LIABILITY APPLICATION Provide responses to the inquiries on this application. If necessary, provide detailed responses on the last page. I. APPLICANT INFORMATION 1. Name : Address:
More informationName of Insurance Company to which Application is made (herein called the Insurer ) DIRECTORS AND OFFICERS INSURANCE APPLICATION
Name of Insurance Company to which Application is made (herein called the Insurer ) DIRECTORS AND OFFICERS INSURANCE APPLICATION Name of Insurance Policy to which Application is applicable NOTICE: THE
More informationMISCELLANEOUS PROFESSIONAL LIABILITY APPLICATION
MISCELLANEOUS PROFESSIONAL LIABILITY APPLICATION CLAIMS MADE AND REPORTED FORM ALL QUESTIONS MUST BE ANSWERED IN FULL. APPLICATION MUST BE SIGNED AND DATED BY THE PRINCIPAL, OFFICER OR PARTNER Applicant
More informationPRIVATE COMPANY INSURANCE POLICY RENEWAL APPLICATION
PRIVATE COMPANY INSURANCE POLICY RENEWAL APPLICATION NOTICE: THE LIABILITY COVERAGE SECTIONS OF THIS POLICY APPLY ONLY TO CLAIMS OR, IF THE PENSION AND WELFARE BENEFIT PLAN FIDUCIARY LIABILITY COVERAGE
More informationSUPPLEMENTAL APPLICATION FOR PROFESSIONAL EMPLOYER ORGANIZATIONS AND TEMP FIRMS
SUPPLEMENTAL APPLICATION FOR PROFESSIONAL EMPLOYER ORGANIZATIONS AND TEMP FIRMS NOTICE: THE POLICY FOR WHICH THIS APPLICATION IS MADE IS A CLAIMS MADE AND REPORTED POLICY SUBJECT TO ITS TERMS. THIS POLICY
More informationEMPLOYEE STOCK OWNERSHIP PLAN QUESTIONNAIRE
EMPLOYEE STOCK OWNERSHIP PLAN QUESTIONNAIRE Name of Insurance Company to which application is made COMPLETION OF THIS QUESTIONNAIRE IS REQUIRED WHEN SEEKING COVERAGE FOR A STANDALONE EMPLOYEE STOCK OWNERSHIP
More informationSMALL ACCOUNTING FIRM PROFESSIONAL LIABILITY APPLICATION NAVIGATORS INSURANCE COMPANY
SMALL ACCOUNTING FIRM PROFESSIONAL LIABILITY APPLICATION NAVIGATORS INSURANCE COMPANY NOTICE: This is an application for a Claims-made policy. Coverage for prior acts and claims made after termination
More informationApplication Trade Credit Insurance Multi Buyer
Chubb Global Markets Political Risk & Credit 1133 Avenue of the Americas New York, NY 10036 (212) 835-3138 (NY) (312) 612-8827 (Chicago) (213) 612-5512 (Los Angeles) Application Trade Credit Insurance
More informationTHE HARTFORD CRIMESHIELD SM ADVANCED POLICY BOND SMALL BUSINESS APPLICATION FOR EMPLOYEE THEFT CLIENT PREMISES ONLY
< >, a stock insurance company, herein called the Insurer THE HARTFORD CRIMESHIELD SM ADVANCED POLICY BOND SMALL BUSINESS APPLICATION FOR EMPLOYEE THEFT CLIENT PREMISES ONLY AGENCY NAME: HARTFORD AGENCY
More informationACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE STANDARD APPLICATION
ACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE STANDARD APPLICATION NOTICE: This is an application for a Claims-made policy. Coverage for prior acts and claims made after termination of this policy may be
More informationPart One Small Firm Application for Miscellaneous Professionals Liability
Part One Small Firm Application for Miscellaneous Professionals Liability Contractors Bonding and Insurance Company Peoria, Illinois 61615 This application applies to firms with revenues less than $1,000,000.
More informationBookkeepers/Tax Preparers Professional Liability Insurance
Bookkeepers/Tax Preparers Professional Liability Insurance To obtain Professional Liability Insurance through North American Professional Liability Insurance Agency, LLC complete the information below,
More informationAbuse And Molestation Liability Application
Abuse And Molestation Liability Application THIS APPLICATION IS ON AN OCCURRENCE COVERAGE BASIS THIS APPLICATION IS ON A CLAIMS-MADE COVERAGE BASIS NOTICE: THIS APPLICATION IS FOR A COVERAGE PART WRITTEN
More informationACE Advantage. Employed Lawyers Professional Liability Application
ACE American Insurance Company Illinois Union Insurance Company Westchester Fire Insurance Company Westchester Surplus Lines Insurance Company ACE Advantage Employed Lawyers Professional Liability Application
More informationEvanston Insurance Company Markel American Insurance Company Markel Insurance Company
Evanston Insurance Company Markel American Insurance Company Markel Insurance Company FOR PROFIT MANAGEMENT LIABILITY RENEWAL APPLICATION BY COMPLETING THIS APPLICATION THE APPLICANT IS APPLYING FOR COVERAGE
More informationAPPLICATION FOR A FINANCIAL INSTITUTION BOND, STANDARD BOND NO. 15, FOR MORTGAGE BANKERS AND INVESTMENT COMPANIES
Underwritten by National Casualty Company Home Office: Columbus, Ohio 43215 Administrative Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258 APPLICATION FOR A FINANCIAL INSTITUTION BOND,
More informationAPPLICATION FOR SECURITIES BROKER-DEALER S PROFESSIONAL LIABILITY GENERAL INFORMATION
APPLICATION FOR SECURITIES BROKER-DEALER S PROFESSIONAL LIABILITY Instructions for Completing This Application Please read carefully and fully answer all questions and submit all requested information
More informationPLEASE READ THE POLICY CAREFULLY
CRIME INSURANCE APPLICATION - MASSACHUSETTS PLEASE READ THE POLICY CAREFULLY Please fully answer all questions and submit all requested information. Terms
More informationAXIS Insurance Telephone: (678) S. Wacker Dr., Ste Toll-Free: (866) Chicago, IL Facsimile: (678)
AXIS Insurance Telephone: (678) 746-9000 111 S. Wacker Dr., Ste. 3500 Toll-Free: (866) 259-5435 Chicago, IL 60606 Facsimile: (678) 746-9315 Website: www.axiscapital.com/en-us/insurance/us#professional-lines
More informationAdditional Included Benefits
Additional Included Benefits In addition to the benefits described in your policy every Named Insured automatically qualifies for additional included benefits designed to minimize your professional liability
More informationEmployee Leasing/Temporary Employment Agency Application
Employee Leasing/Temporary Employment Agency Application All questions must be answered in full. Application must be signed and dated by the applicant. Applicant s Name Agent Applicant Mailing Address
More informationProperty/Casualty Insurance Renewal Survey
P.O. Box 5670 Cortland, NY 13045 Phone (800) 822-3747 Fax: (607) 756-5051 Email: applications@ mcneilandcompany.com GENERAL INFORMATION Date of survey: Renewal Date: Date proposal needed: Legal Name of
More informationHOME INSPECTORS PROFESSIONAL LIABILITY INSURANCE APPLICATION THIS INSURANCE, IF ISSUED, WILL BE ON A CLAIMS-MADE AND REPORTED BASIS.
800 Oak Ridge Turnpike, Suite A-1000 Oak Ridge, Tennessee 37830 HOME INSPECTORS PROFESSIONAL LIABILITY INSURANCE APPLICATION THIS INSURANCE, IF ISSUED, WILL BE ON A CLAIMS-MADE AND REPORTED BASIS. NOTICE:
More informationHIRED AND NON-OWNED AUTOMOBILE SUPPLEMENTAL APPLICATION
HIRED AND NON-OWNED AUTOMOBILE SUPPLEMENTAL APPLICATION PLEASE ANSWER ALL QUESTIONS IF THEY DO NOT APPLY, INDICATE NOT APPLICABLE (N/A) Applicant Name: HIRED AUTO INFORMATION Coverage Subject to Audit
More informationAXIS Insurance Telephone: (678) S. Wacker Dr., Ste Toll-Free: (866) Chicago, IL Facsimile: (678)
AXIS Insurance Telephone: (678) 746-9000 111 S. Wacker Dr., Ste. 3500 Toll-Free: (866) 259-5435 Chicago, IL 60606 Facsimile: (678) 746-9315 Website: www.axiscapital.com/en-us/insurance/us#professional-lines
More informationAddress: City: State: Zip Code: Publicly Traded Private Corporation Limited Liability Company Sole Proprietorship Partnership Joint Venture
APPLICATION FOR DIRECTORS & OFFICERS LIABILITY COVERAGE (Complete if coverage is requested for Directors & Officers and Corporate Securities Liability or Private Company Management Liability) NOTICE: THE
More informationXL Eclipse 2.0 Renewal Application
XL Eclipse 2.0 Renewal Application Third Party Coverage Technology & Miscellaneous Professional Services Technology Products Media Communications Network Security Privacy Liability First Party Coverage
More informationIF YES TO THE ABOVE, PLEASE RESPOND TO THE FOLLOWING QUESTIONS. IF NO, PLEASE SIGN, DATE AND RETURN TO THE UNDERWRITER.
Hartford Fire Insurance Company UNDERWRITING QUESTIONNAIRE SERVICING CONTRACTORS NAME OF INSURED: 1. Do you currently use independent contractors for servicing loans? IF YES TO THE ABOVE, PLEASE RESPOND
More informationCPAOnePro Risk Purchasing Group Application
Underwritten by The Hanover Insurance Company CPAOnePro Risk Purchasing Group Application CLAIMS-MADE WARNING FOR APPLICATION THIS POLICY PROVIDES COVERAGE ON A CLAIMS-MADE BASIS. SUBJECT TO ITS TERMS,
More informationAPPLICATION FOR INSURANCE COMPANY PROFESSIONAL LIABILITY COVERAGE
APPLICATION FOR INSURANCE COMPANY PROFESSIONAL LIABILITY COVERAGE NOTICE: THE POLICY WHICH YOU ARE APPLYING IS A CLAIMS-MADE POLICY. THE POLICY COVERS ONLY CLAIMS FIRST MADE AGAINST THE INSUREDS DURING
More informationTELECOMMUNICATION TOWERS SUPPLEMENTAL APPLICATION (Complete in addition to the ACORD General Liability Application)
TELECOMMUNICATION TOWERS SUPPLEMENTAL APPLICATION (Complete in addition to the ACORD General Liability Application) Applicant s Name: Agent Name: Agent Address: Location Address: Phone No.: PROPOSED EFFECTIVE
More informationTravelers 1 st Choice ACCOUNTANTS PROFESSIONAL LIABILITY COVERAGE RENEWAL APPLICATION
Travelers 1 st Choice ACCOUNTANTS PROFESSIONAL LIABILITY COVERAGE RENEWAL APPLICATION SM Travelers Casualty and Surety Company of America Hartford, Connecticut Important Note: This is an application for
More informationTravelers 1 st Choice ACCOUNTANTS PROFESSIONAL LIABILITY COVERAGE APPLICATION
Travelers 1 st Choice ACCOUNTANTS PROFESSIONAL LIABILITY COVERAGE APPLICATION SM Travelers Casualty and Surety Company of America Hartford, Connecticut Important Note: This is an application for a claims-made
More informationProfessional Liability Errors and Omissions Insurance Application
Professional Liability Errors and Omissions Insurance Application If coverage is issued, it will be on a claims-made basis. Notice: this insurance coverage provides that the limit of liability available
More informationPRIVATE COMPANY THIRD PARTY ADMINISTRATOR QUESTIONNAIRE
PRIVATE COMPANY THIRD PARTY ADMINISTRATOR QUESTIONNAIRE NAME OF APPLICANT COMPANY (or you ): ADDRESS: DATE: 1. Do clients audit you to the extent of the service you provide them? a. How is the audit performed?
More informationAPPLICATION FOR A FINANCIAL INSTITUTION BOND, STANDARD FORM NO. 25 FOR INSURANCE COMPANIES. Application is hereby made by
APPLICATION FOR A FINANCIAL INSTITUTION BOND, STANDARD FORM NO. 25 FOR INSURANCE COMPANIES This form must be completed for each new bond and at each premium anniversary. If more space is needed to answer
More informationPresent Crime Insurance Program: (Include primary AND excess, if applicable) If not applicable, please check here:
, a stock insurance company, herein called the Insurer The Hartford CrimeSHIELD Advanced Policy EMPLOYEE THEFT CLIENT PREMISES (THEFT OF CLIENT S PROPERTY APPLICATION) Agency Name: Billing Method: Agency/Broker
More informationAdditional Named Insured / Physician Application for Professional Liability Coverage
Additional Named Insured / Physician Application for Professional Liability Coverage Type of coverage: Medi cal Professional Liability First Name Middle Name or Initial Last Name Suffix Previous Last Name(s)
More information376 Broadway, PO Box 1038, Schenectady, NY Toll free: 877- MERRIAM ( )
376 Broadway, PO Box 1038, Schenectady, NY 12301-1038 Toll free: 877- MERRIAM (637-7426) TITLE AGENT PROFESSIONAL LIABILITY - ERRORS AND OMISSIONS INSURANCE APPLICATION THIS IS A CLAIMS MADE AND REPORTED
More informationAPL InNAVation(sm) ACCOUNTANT S PROFESSIONAL LIABILITY APPLICATION
APL InNAVation(sm) ACCOUNTANT S PROFESSIONAL LIABILITY APPLICATION (THIS IS AN APPLICATION FOR A CLAIMS MADE POLICY) 1. NAME OF FIRM 2. ADDRESS: (a) ADDRESSES OF BRANCH OFFICES:.. (b) A PARTNER OR OFFICER
More informationNational Union Fire Insurance Company of Pittsburgh, Pa. LAWYERS PROFESSIONAL LIABILITY RENEWAL APPLICATION
National Union Fire Insurance Company of Pittsburgh, Pa. (herein called the Insurer ) LAWYERS PROFESSIONAL LIABILITY RENEWAL APPLICATION NOTICE THIS IS AN APPLICATION FOR INSURANCE WRITTEN ON A CLAIMS
More informationFIDUCIARY LIABILITY INSURANCE MAINFORM APPLICATION
FIDUCIARY LIABILITY INSURANCE MAINFORM APPLICATION THIS IS AN APPLICATION FOR A POLICY THAT IS WRITTEN ON A CLAIMS-MADE BASIS AND COVERS ONLY CLAIMS FIRST MADE AGAINST THE INSUREDS DURING THE POLICY PERIOD
More informationNON-PROFIT ORGANIZATION MANAGEMENT LIABILITY APPLICATION
NON-PROFIT ORGANIZATION MANAGEMENT LIABILITY APPLICATION NOTICE: THIS IS A CLAIMS MADE AND REPORTED POLICY THAT APPLIES ONLY TO THOSE CLAIMS FIRST MADE AGAINST THE INSURED DURING THE POLICY PERIOD AND
More informationCOMMERCIAL INLAND MARINE APPLICATION
PO BOX 3867, Bellevue, WA 98009 P: 800.562.8095 I F: 425.453.8696 submissions@gogus.com COMMERCIAL INLAND MARINE APPLICATION (Animal Floater, Golf Carts, Signs) Applicant s Name: Agency Name: Agent: Mailing
More informationLANDSCAPING GENERAL LIABILITY APPLICATION
LANDSCAPING GENERAL LIABILITY APPLICATION Applicant s Name: Mailing Address: Agency Name: Agent No.: Address: Location Address: E-mail: PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the
More informationNew England Excess Exchange, Ltd. P O Box 219 ~ Montpelier VT ~ ~ Fax Web Site:
New England Excess Exchange, Ltd. P O Box 219 ~ Montpelier VT 05601 ~ 800-548-4301 ~ Fax 800-347-4935 Web Site: www.neee.com APPLICATION FOR ACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE (CLAIMS-MADE BASIS.
More informationHired and Non-Owned Liability Supplemental Application All questions must be answered in full. Application must be signed and dated by the applicant.
Agency Name: Address: Contact Name: Phone: Fax: Email: Applicant s Name Hired and Non-Owned Liability Supplemental Application All questions must be answered in full. Application must be signed and dated
More informationAXIS BUSINESS INTERRUPTION & DATA RESTORATION- SYSTEM FAILURE SUPPLEMENTAL APPLICATION
AXIS Insurance Telephone: (678) 746-9000 111 S. Wacker Dr., Ste. 3500 Toll-Free: (866) 259-5435 Chicago, IL 60606 Facsimile: (678) 746-9315 Website: www.axiscapital.com/en-us/insurance/us#professional-lines
More informationAddress: City: State: Zip Code:
RENEWAL APPLICATION FOR ASSET MANAGEMENT LIABILITY Directors & Officers Liability/Investment Adviser Professional Liability/Investment Fund Management & Professional Liability NOTICE: THE POLICY WHICH
More informationMiscellaneous Professional Liability Insurance Home Inspectors New Business Application
Hanover Professional Portfolio Miscellaneous Professional Liability Insurance Home Inspectors New Business Application CLAIMS-MADE WARNING FOR APPLICATION THIS APPLICATION IS FOR A CLAIMS-MADE AND REPORTED
More informationErrors and Omissions Liability Insurance Renewal Application This application is for a Claims Made and Reported Policy
14280 Park Meadow Drive, Suite 300 Phone: 703-652-1300 or 800-356-6886 Chantilly, VA 20151-2219 Fax: 703-652-1389 Renewal Application This application is for a Claims Made and Reported Policy Please answer
More informationACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE APPLICATION
Kinsale Insurance Company P. O. Box 17008 Richmond, VA 23226 (804) 289-1300 www.kinsaleins.com ACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE APPLICATION APPLICANT S INFORMATION 1. Legal name of the business
More informationEXTERMINATORS APPLICATION
PO BOX 3867, Bellevue, WA 98009 P: 800.562.8095 I F: 425.453.8696 submissions@gogus.com EXTERMINATORS APPLICATION Applicant s Name: Agency Name: Agent No.: Mailing Address: Address: E-mail: Phone No.:
More informationRESIDENTS OF FLORIDA ONLY 1. APPLICANT INFORMATION (All applicants must complete. Please print all information.)
American Health Information Management Association AHIMA PROFESSIONAL LIABILITY INSURANCE APPLICATION EMPLOYED PROFESSIONALS AND STUDENTS Underwritten by Liberty Insurance Underwriters Inc. How to apply:
More informationAXIS Insurance Telephone: (678) S. Wacker Dr., Ste Toll-Free: (866) Chicago, IL Facsimile: (678)
AXIS Insurance Telephone: (678) 746-9000 111 S. Wacker Dr., Ste. 3500 Toll-Free: (866) 259-5435 Chicago, IL 60606 Facsimile: (678) 746-9315 Website: www.axiscapital.com/en-us/insurance/us#professional-lines
More informationAPPLICATION FOR Social Services Not-For-Profit Management Liability
APPLICATION FOR Social Services t-for-profit Management Liability Section A. APPLICANT INFORMATION: Name of Applicant: Address: Website address: Description of Services or purpose of Organization: Number
More informationAXIS Insurance Telephone: (678) S. Wacker Dr., Ste Toll-Free: (866) Chicago, IL Facsimile: (678)
AXIS Insurance Telephone: (678) 746-9000 111 S. Wacker Dr., Ste. 3500 Toll-Free: (866) 259-5435 Chicago, IL 60606 Facsimile: (678) 746-9315 Website: www.axiscapital.com/en-us/insurance/us#professional-lines
More informationMiscellaneous Professional Liability Insurance New Business Application
Miscellaneous Professional Liability Insurance New Business Application CLAIMS-MADE WARNING FOR APPLICATION THIS APPLICATION IS FOR A CLAIMS-MADE AND REPORTED POLICY. SUBJECT TO ITS TERMS, THIS POLICY
More informationHow to Apply for Long Term Disability Conversion Insurance
How to Apply for Long Term Disability Conversion Insurance Please follow these steps to apply for Conversion: 1. Complete the LTD Conversion Application provided in this package. Please answer each question
More informationTREE TRIMMERS GENERAL LIABILITY APPLICATION
Scottsdale Insurance Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Adm. Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258 Scottsdale Surplus Lines Insurance Company Adm.
More informationINSURANCE AGENT & BROKER PROFESIONAL LIABILITY APPLICATION
INSURANCE AGENT & BROKER PROFESIONAL LIABILITY APPLICATION Instructions: Please answer all questions. If the answer is none, state none. If the answer is not applicable state N/A. If the space provided
More informationMiscellaneous Professional Liability Application
AMERICAN INTERNATIONAL COMPANIES Name of insurance company to which Application is made (the Insurer ) Miscellaneous Professional Liability Application NOTICE: THE POLICY PROVIDES THAT THE LIMIT OF LIABILITY
More informationPRIVATE COMPANY MANAGEMENT LIABILITY APPLICATION
PRIVATE COMPANY MANAGEMENT LIABILITY APPLICATION NOTICE: THIS IS A CLAIMS MADE AND REPORTED POLICY THAT APPLIES ONLY TO THOSE CLAIMS FIRST MADE AGAINST THE INSURED DURING THE POLICY PERIOD AND REPORTED
More informationGARAGE RENEWAL APPLICATION
GARAGE RENEWAL APPLICATION 1. Policy Number: Renewal Period: From: To: 2. Business Trade Name: Insured: 3. Has the Named Insured or Location changed?... Yes No 4. New Mailing Address: City: 5. County:
More informationPENSION and BENEFIT PLAN FIDUCIARY LIABILITY INSURANCE APPLICATION
Name of Insurance Company to which application is made PENSION and BENEFIT PLAN FIDUCIARY LIABILITY INSURANCE APPLICATION NOTICE: THIS IS A CLAIMS-MADE AND REPORTED POLICY. EXCEPT AS MAY OTHERWISE BE PROVIDED
More informationPROFESSIONAL LIABILITY INSURANCE FOR AGENTS AND BROKERS APPLICATION
COMPANY PROVIDING COVERAGE: Greenwich Insurance Company Indian Harbor Insurance Company PROFESSIONAL LIABILITY INSURANCE FOR AGENTS AND BROKERS APPLICATION NOTICE The Insurance coverage for which you are
More informationPolicyholder/Entity Name: Licensed State: Organization NPI Number:
1. Entity Information Podiatry Insurance Company of America Insured Organization Application This is an Application for a Claims-Made Policy. PLEASE PRINT CLEARLY AND ANSWER ALL QUESTIONS. Submission of
More informationACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE
ACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE GREAT AMERICAN ASSURANCE COMPANY EXPRESS APPLICATION To be eligible for this application you must be able to answer "True" to statements 1-9 below. Please contact
More informationBREACH RESPONSE INFORMATION SECURITY & PRIVACY INSURANCE WITH BREACH RESPONSE SERVICES
CG HIIG AP 01 02 17 BREACH RESPONSE INFORMATION SECURITY & PRIVACY INSURANCE WITH BREACH RESPONSE SERVICES SHORT FORM APPLICATION NOTICE: INSURING AGREEMENTS 1., 3., 4. AND 5. OF THIS POLICY PROVIDE COVERAGE
More informationADULT DAY CARE APPLICATION
PO BOX 3867, Bellevue, WA 98009 P: 800.562.8095 I F: 425.453.8696 submissions@gogus.com ADULT DAY CARE APPLICATION (Not Applicable to Adult Family Homes) ADULT DAY CARE GENERAL LIABILITY APPLICATION Applicant
More informationMULTI-EMPLOYER PENSION and BENEFIT PLAN FIDUCIARY LIABILITY INSURANCE APPLICATION
Name of Insurance Company to which application is made MULTI-EMPLOYER PENSION and BENEFIT PLAN FIDUCIARY LIABILITY INSURANCE APPLICATION NOTICE: THIS IS AN APPLICATION FOR A CLAIMS-MADE AND REPORTED POLICY.
More informationMPL SECURE: MISCELLANEOUS PROFESSIONAL AND NETWORK SECURITY LIABILITY INSURANCE POLICY
RENEWAL APPLICATION AFB MEDIA TECH PROFESSIONAL AND TECHNOLOGY BASED SERVICES, TECHNOLOGY PRODUCTS, COMPUTER NETWORK SECURITY, AND MULTIMEDIA AND ADVERTISING LIABILITY INSURANCE POLICY MISCELLANEOUS PROFESSIONAL
More informationFinancial Institutions Title Agents E&O Application
Financial Institutions Title Agents E&O Application *To be able to save this form after the fields are filled in, you will need to have Adobe Reader 9 or later. If you do not have version 9 or later, please
More informationCARRIER: Applicant s name: City: State: Zip code: Website address: address of primary contact:
CARRIER: This application is for a Claims Made policy. Please read your policy carefully. Defense costs shall be applied against the deductible (except in New York). Applicant may qualify for an INSTANT
More informationTHE HARTFORD CRIMESHIELD SM ADVANCED POLICY BOND SMALL BUSINESS APPLICATION FOR COMMERCIAL, NON PROFIT AND GOVERNMENTAL ENTITIES
, a stock insurance company, herein called the Insurer THE HARTFORD CRIMESHIELD SM ADVANCED POLICY BOND SMALL BUSINESS APPLICATION FOR COMMERCIAL, NON PROFIT AND GOVERNMENTAL ENTITIES AGENCY NAME: HARTFORD
More informationCorporate Directors and Officers Liability, Employment Practices Liability and Fiduciary Liability
USLI.COM 888-523-5545 Corporate Directors and Officers Liability, Employment Practices Liability and Fiduciary Liability THE ANSWER All questions must be answered and application must be signed by the
More informationTHE HARTFORD CRIMESHIELD SM ADVANCED POLICY BOND SMALL BUSINESS APPLICATION FOR CONDOMINIUM, HOMEOWNERS, AND COOPERATIVE ASSOCIATIONS
Hartford Fire Insurance Company, a stock insurance company, herein called the Insurer THE HARTFORD CRIMESHIELD SM ADVANCED POLICY BOND SMALL BUSINESS APPLICATION FOR CONDOMINIUM, HOMEOWNERS, AND COOPERATIVE
More informationCity: County: State: Zip Code: address: Website: Business Phone:
APPLICATION FOR ACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE (CLAIMS-MADE BASIS) Insight Insurance 2000 S. Batavia Ave., Suite 300 Geneva, IL 60134 Toll Free Telephone (800) 447-4626 Telephone (630) 208-1900
More informationFiduciary & Employee Benefits Liability Application
FDIC #: DATE: *To be able to save this form after the fields are filled in, you will need to have Adobe Reader 9 or later. If you do not have version 9 or later, please download the free tool at: http://get.adobe.com/reader/.
More informationSolar or Wind Energy Facilities Application
Solar or Wind Energy Facilities Application All questions must be answered in full. Application must be signed and dated by the applicant. APPLICANT S NAME AND MAILING ADDRESS AGENT / PRODUCER INFORMATION
More informationArtisan Contractors Application
Artisan Contractors Application All questions must be answered in full. Application must be signed and dated by the applicant. APPLICANT S NAME AND MAILING ADDRESS AGENT / PRODUCER INFORMATION APPLICANT
More informationEXTERMINATORS GENERAL LIABILITY APPLICATION. Agency Name: Agent No.: Address: Phone No.:
Roush Insurance Services, Inc. PO Box 1060 Noblesville, IN 46061-1060 Phone: (800) 752-8402 Fax: (317) 776-6891 www.roushins.com Email: quote@roushins.com EXTERMINATORS GENERAL LIABILITY APPLICATION Applicant
More informationEDUCATORS PROFESSIONAL LIABILITY INSURANCE PLAN APPLICATION CLAIMS-MADE PROFESSIONAL LIABILITY Underwritten By: Liberty Insurance Underwriters Inc.
EDUCATORS PROFESSIONAL LIABILITY INSURANCE PLAN APPLICATION CLAIMS-MADE PROFESSIONAL LIABILITY Underwritten By: Liberty Insurance Underwriters Inc. HOW TO APPLY: 1. Complete application below. 2. Note
More informationACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE GREAT AMERICAN ASSURANCE COMPANY EXPRESS APPLICATION
ACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE GREAT AMERICAN ASSURANCE COMPANY EXPRESS APPLICATION To be eligible for this application you must be able to answer true to statements 1-9 below. For optional
More informationDIRECTORS, OFFICERS AND COMPANY LIABILITY INSURANCE POLICY APPLICATION
BEAZLEY DIRECTORS, OFFICERS AND COMPANY LIABILITY INSURANCE POLICY APPLICATION NOTICE: THE POLICY FOR WHICH THIS APPLICATION IS MADE IS A CLAIMS MADE AND REPORTED POLICY SUBJECT TO ITS TERMS. THIS POLICY
More informationAPPLICATION FOR IDL INSURANCE
Home Office: One Nationwide Plaza Columbus, Ohio 43215 Administrative Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258 1-800-423-7675 APPLICATION FOR IDL INSURANCE UNLESS OTHERWISE PROVIDED
More information