Insurance Inquiry - E&O

Applicant Name *
Applicant Name
Date applicant firm was established
Date applicant firm was established
Mailing Address
Mailing Address
Phone
Phone
Legal Entity
Describe in detail the services for which coverage is desired in this format: Service Offered, Percent of total.
Total Expected Revenue for the upcoming policy period:
Does the applicant firm utilize the services of Independent Contractors?
Please include with application all Principal and Key Employee resumes in this format: Name, Professional Qualifications, Years Experienced.
# of full time
# of part time
Please list professional associations to which the Applicant belongs:
Please list the Applicant's three largest jobs or projects during the past three years in format: Name of Job, Services Performed for Client, Pct. Of Gross Revenue.
Please list the Applicant's Professional Liability Insurance Coverage carried during the past three years, including any periods without coverage in this format: Name of Insurer, Policy Period: From to, Deductible.
Claim History
Have any claims for past five years?
Proposed Effective Date
Proposed Effective Date
Does the applicant sell Real Estate?
Please check below if the Applicant or the Applicant's predecessor firm, at any time in the past or present, engaged in any business venture outside the scope of a Property Manager, including but not limited to:
Insurance Agent, Insurance Broker or Insurance Salesperson
Residential: %, Commercial/Office: %, Retail: %, Industrial: %, Other %