Name of Applicant*

Street Address*

City*State*ZIP*

Phone Number*Email Address*Website Address*Business Estb. Year*

Description of operations*SIC code, if known(4-digit number)*

Is the applicant a subsidiary of a foreign parent?*YesNo

Does the Applicant currently file, or does it anticipate filing in the next 6 months, any documents with the Securities and Exchange Commission or similar foreign authority regarding any equity or debt securities?*YesNo

Organization Information

Describe all entities the Applicant owns(check here if not applicable):Check Here

NamePercentage OwnedYear Started

Description of Operations

Entity Type:FPNPGPLPLLCFP=For Profit, (other than Partnership); NP=Non-Profit; GP=General Partnership; LP=Limited Partnership; LLC=Limited Liability Company

In the next 12 months(or during the past 24 months) is the Applicant contemplating (or has the Applicant completed or been in the process of completing) the following:

Any actual or proposed merger, acquisition, or divestiture?*YesNoAny Creation of a new business, subsidiary, or division?*YesNoAny registration for a public offering or a private placement of securities?*YesNoAny reorganization or arrangement with creditors under federal or state law?*YesNoAny Branch, location, facility, office, or subsidiary closings, consolidations, or layoffs?*YesNo

Describe, in detail, all professional services offered by the Applicant:

Professional Services*% of Total Revenue*% of revenue Sub-contracted*

Indicate Applicant’s revenue for the following years:

Prior Fiscal Year*Current Fiscal Year*Estimation for next fiscal year*

Describe the Applicant’s 5 largest projects or jobs during the past 3 years:

Client's Name*Services Rendered*Annual Revenue Derived From the Project of Job*

Client's Name*Services Rendered*Annual Revenue Derived From the Project of Job*

Client's Name*Services Rendered*Annual Revenue Derived From the Project of Job*

Client's Name*Services Rendered*Annual Revenue Derived From the Project of Job*

Client's Name*Services Rendered*Annual Revenue Derived From the Project of Job*

If Sub-contractors are used, does the Applicant require evidence of professional liability insurance?*YesNo

Is A written Contract or Agreement required for each client?*YesNo

If Yes, please attach a sample. If No, please attach an explanation detailing how responsibilities are defined between the applicant and client.

Has the Applicant sued to collect past or overdue fees from clients within the past 2 years?*YesNo

If Yes, please attach an explanation.

Does the applicant use:

A procedure manual?*YesNoA formal training Program*YesNo

Indicate the number of Applicant’s employee:

Principals/Partners, Officers, Professionals*Clerical/Non-Professional*

Indicate the following information for all Principals/Partners, Officers, and professional employees.

Name*Title*Professional Designation*

No. of years' experience in practice*No. of years' with applicant*

List All professional Associations to which Application belongs*

Current Insurance Information/Requested Insurance Terms:

Requested Limit($)*Requested Retention($)*Requested Effective Date*

Coverage Currently Purchased*YesNoCurrent Insurer*YesNo

Expiring Limit($)*Expiring retention($)*Expiring Premium($)*

Date Coverage First Purchased*Current Retroactive Dated*

What is the Applicant’s preference for Defense coverage?*Duty to DefendReimbursement

Loss Information

Is the Applicant or any person proposed for this insurance aware of any fact circumstance, situation, event or act that reasonably could give rise to a claim against them under the Liability Coverage for which the Applicant is applying?*YesNo

If Yes, please attach an explanation

With respect to the information required to be disclosed in response to the question above, the proposed insurance will not afford coverage for any claim arising from any fact, circumstance, situation, event or act about which any executive officer of the Applicant had knowledge prior to the issuance of the proposed policy, nor for any person of entity who knew of such fact, circumstance, situation, event or act prior to the issuance of the proposed policy.

Loss Information

Has any person or entity proposed for this insurance been a party to any professional liability claims, any disciplinary actions, or been cited by any regulatory agency or professional association during the past 5 years?*YesNo

If Yes, please attach an explanation

Date of such claim*Nature of Claim*Amount paid for defense*

Amount sought / paid for damages*Covered by insurance*YesNoCorrective Procedures Implemented*

Current Status*Notes*

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