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Professional Liability Online Application

Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Personal Information

First Name(Required)

Last Name(Required)

Number of Owners(Required)

Name(s) of Company Owner(s), with % ownership(Required)

Description of Operations:(Required)

Formal Name of Business(Required)

Is your company a franchise?(Required)

If yes, provide full legal name of franchisor:

Business Type(Required)

Street(Required)

City(Required)

State(Required)

ZIP / Postal Code(Required)

Primary Phone Number(Required)

E-Mail Address(Required)

Website Address:(Required)

Year Established(Required)

How many years of experience do you have?(Required)

Do you perform services in the State of New York?(Required)

If “Yes,” what percentage is performed in the five (5) boroughs and what percent in the rest of New York?

Please list all States in which you operate.(Required)

Estimated Annual Gross Revenue(Required)

Prior 12 months annual gross revenue(Required)

Number of full-time employees(Required)

Number of part-time employees(Required)

Number of temporary/ seasonal employees(Required)

Number of independent contractors (Required)

By category, provide estimated annual payroll paid to: owners, employees, temporary/seasonal and independent contractors.(Required)

Do you use subcontractors?(Required)

When hiring subcontractors, check off all that apply:(Required)

Hold down the Ctrl Key to make multiple selections.

What percentage of your work includes the subcontracting of work to others?(Required)

Annual Cost of Subcontractors(Required)

Are subconsultants and subcontractors hired under a written, standard subcontract?(Required)

Does your company use a standard written contract with clients?(Required)

Do you get this contract signed 100% of the time?(Required)

Does your contract contain a limitation of liability and an aribtration clause? (Required)

Do you provide written warranties for your work?(Required)

Do you use subcontractors?(Required)

When hiring subcontractors, check off all that apply:(Required)

Hold down the Ctrl Key to make multiple selections.

What percentage of your work is subcontracted to others?(Required)

Annual Cost of Subcontractors(Required)

Does your company use a standard written contract with clients?(Required)

Do you get this contract signed 100% of the time?(Required)

Advise if your contracts contain these items:(Required)

Hold down the Ctrl Key to make multiple selections.

Does your contract contain a limitation of liability and an aribtration clause? (Required)

Do you provide written warranties for your work?(Required)

How many years have you continuously had Professional Liability (E&O) coverage?(Required)

Effective Date

Current Policy End Date(Required)

Current Limits(Required)

Current Deductible(Required)

Current Premium(Required)

Has any entity proposed for insurance closed, sold, merged with or acquired any company in the past 12 months or anticipates doing so in the next 12 months?(Required)

Does the firm currently have General Liability Insurance in place?(Required)

If yes, please provide name of General Liability insurer and approximate expiration date:(Required)

Number of E&O insurance claims filed with insurance carriers in the last 5 years:(Required)

Do you have knowledge of any circumstance, act, error, or omission that could result in a professional liability claim?(Required)

Has Professional Liability (E&O) insurance ever been non-renewed or cancelled?(Required)

Additional Comments