E&O Application

General Information

Applicant Name*

Has the name or structure of the Applicant ever changed, or has there been an acquisition, consolidation, merger, dissolution, reconstitution, or any other change?*
Yes No

If you have retro coverage, any past name, DBA, or entity must be named on the policy for coverage.

Provide Details*

Applicant Contact Name and Title*

Physical Address*

Address Line 2

City*

State*

Zip*

Mailing Address (if different)

Address Line 2

City

State

Zip

County

Website

Phone*

Fax

Email Address*

Year Business Established*

Number of Locations*

Officers & Owners

List officers/owners and complete information below.

Name*

Birth Year

Title

Ownership %* %

Active in Daily Business?*
Yes No

Ownership 0%

+ Add Another Officer/Owner

Total Number of Employees*

Do all active Owners, Officers, or Key Employees performing Professional Services have more then 3 year's experience?*
Yes No

Subcontractors

If any services are performed by an outside party, are they required to carry their own E&O liability insurance?*
Yes No N/A

The Applicant warrants and/or certifies that it will continue to require subcontractors to obtain and maintain E&O insurance during the life of this policy.

Attach a current Declarations Page or Certificate of Insurance for each subcontractor.

What percent of your independent contractors carry E&O liability insurance?

Current / Prior Insurance

Does Applicant have E&O liability insurance currently in force?*
Yes No

Current Carrier

Current Limits

Deductible

Expiration Date*

Expiring Premium $

Retro or Prior Acts Date

Current Declarations Page

Business Arrangements

Is 20% or more of Applicant's work directly from builders during construction or development of property?*
Yes No

Verification

I understand that insurance coverage and/or claims cannot be submitted, bound, amended, cancelled, changed or managed through this form.

I verify I have reviewed and accepted our Notices. I also acknowledge that I can opt out of future email correspondence, delivery of future quote or policy documentation or other digital correspondence by emailing [email protected] .

By typing my name to digitally sign this application in the box below, I agree that after inquiry of all applicants and prospective insureds, no person proposed for coverage is aware of any fact or circumstance which reasonably might give rise to a future claim that would fall within the scope of the proposed coverage.

Authorized Signature

Date

Title Agent

Escrow Agent / Closer

Total