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Professional Liability Quote Request

BUSINESS OWNERS PROGRAM
Professional Liability Quote Request
1
 Contact Information
 
 Name of Business
 
 Contact Name:
 
 Address:
 
 Address 2:
 
 City - St - Zip:
 
 Phone Number:       FAX
 
 E-Mail Address:
2
 Please describe in detail all Professional Services that your business provides that you would like to have covered under this policy. Note: Coverage will only be provided for those services listed on the policy as Professional Services.
3
 What are the total gross receipts/revenues, by state, derived from the Professional Services described in number 1 above? $
4
 How many years of experience does your organization have providing the Professional Services described in number 1 above?
5
 Does your firm conduct qualification inquiries on all potential hires?
YES NO
6
 Total number of professional employees (employees providing professional services as described in number 1 above) employed by the applicant in the last 12 months (all locations).
Year
Number of Employees
7
Total Number of professional employees that were terminated by the applicant and the total number of employees that voluntarily left their employment in the last 12 months (all locations).
Year
Terminated
Voluntarily Left
8
 Have any Professional Liability claims been made against you within the past 3 years?
YES NO
Date
Description
Total Amount of Loss
9
 Is the applicant aware of any facts, incidents or circumstances which may result in any Professional Liability losses, claims or suits being made against them? YES NO
If yes, please provide details.
10
 Have any of the principals, partners, officers or professional employees ever been the subject of disciplinary action by authorities as a result of their professional activities? YES NO
If yes, please provide details.
11
 Desired Limits: (Each Wrongful Act / Aggregate) (other limits may be available upon request)
$100,000/$100,000
$250,000/$250,000
$500,000/$500,000
$750,000/$750,000
$1,000,000/$1,000,000
$2,000,000/$2,000,000
12
 Desired Deductible: (Each Wrongful Act)
$500
$1,000
$2,500
$5,000 $7,500 $10,000
$15,000
$20,000
$25,000
13
 Is your business currently covered by a Professional Liability policy?
YES NO
14 Please indicate whether the following optional coverages are desired:
Coverage for Wrongful Acts that take place outside of the United States of America, it’s territories and possessions, Puerto Rico, or Canada; and Increased limits for earnings lost from $100 to $1,000 per day? YES NO