-- QUAKER PRO
--
CONSULTANTS PROFESSIONAL LIABILITY
APPLICATION
tel: 800-447-4180 fax: 732-223-9072
THIS IS AN APPLICATION FOR A CLAIMS MADE POLICY
SECTION I-BACKGROUND INFORMATION
1. Name of
Insured:________________________________________________________________________
2.
Address:______________________________________________________________________________
Website:_______________________________________________________________________________
3. Limits of Liability desired: ( ) $250,000
( ) $500,000
( ) $1,000,000
4. Deductible: ( ) $1,000 (
) $2,500 ( ) $5,000
( ) $10,000
5. Date Established:
________________________________________________________________________
6. Is Insured: ( ) Individual
( ) Corporation ( ) Partnership ( )
Other: _____________________________
7. Is the Applicant controlled, owned, affiliated or associated with any
other firm, corporation or
company? ( ) YES ( ) NO
8. Does the Applicant have any Subsidiaries? ( )
YES ( ) NO If YES, please list on a separate
sheet and advise if coverage is to apply to them.
9. During the past five years has the name of the firm been changed or
has any other business been
acquired, merged into or consolidated with any other
firm , corporation, or company?
( ) YES ( )
NO (if yes please attach an explanation and advise if any liabilities have been assumed
as a result of the merger, acquisition or
consolidation).
SECTION II -ORGANIZATION OPERATION DETAILS
10. Please describe in detail the
professional services for which coverage is desired:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
11. (a) List total gross receipts derived from activities in question #10:
Gross Receipts Last Year: $________________________________ Current Year (based on 12 months): $________________________________ Forecast for Next Year: $________________________________
(b) Does the Applicant receive any compensation other
than money (stocks, options...) for providing
professional services?
( ) YES ( ) NO If YES, advise details.
______________________________
12 (a) Does the Applicant derive income from any activity or profession other than
what is described
in question #10?
( ) YES ( )
NO If YES, please attach an explanation and estimated receipts (advise if these
receipt were included
in question #10).
(b) Is the Applicant a licensed Professional (i.e. Lawyer,
Accountant...) ( ) YES ( ) NO
if YES, advise type of
Licensed Professional:______________________________________________
13. (a) Describe the (5) five largest jobs or projects during the past 3 years
NAME OF CLIENT SERVICES PROVIDED GROSS BILLINGS/FEES ____________________________ _____________________ ______________________ __________________________ _____________________ ______________________ __________________________ _____________________ ______________________ ___________________________ _____________________ ______________________ ___________________________ ______________________ _______________________
(b) Was more than 50% of Applicant's total gross billings for
any one year derived from a single
client or contract?
( ) YES ( ) NO If YES, specify client, services rendered
and how long
relationship is expected to
continue:
(c) Describe any jobs or projects anticipated during the next 12
months that will result in more than
10% of Applicant's gross receipts
(not already listed in #13 a)___________________________________
___________________________________________________________________________________
____________________________________________________________________________________
END - PAGE - 1
14.(a) Advise the number of: principals, partners, officers and professional
employees directly engaged
in providing services to
clients ____________________________________________________________
(b) Advise the number of all other (non-
professional/clerical) employees _______________________________
(c) Advise the number of independent/sub contractors doing
work on your behalf ________________________
15. Does the Applicant desire to provide coverage under the Policy for independent/sub
contractors working on their behalf? ( )
YES ( ) NO If YES, advise on separate sheet:
(a) How the Applicant utilizes each
independent/subcontractor.
(b) The total percent of Applicant's work done by
independent/sub contractors.
(c) Does the Applicant require Certificates of Insurance
from all independent/sub contractors.
16. Please provide the following: (attach separate sheet if necessary)
Name of all Partners, Principals,
Key Employees and
Independent/Sub ContractorsProfessional
Qualifications/
Designations# of Years
in Practice# of Years
with Applicant______________________________ _____________ __________ ___________ ______________________________ _____________ __________ ___________ ______________________________ _____________ __________ ___________ ______________________________ _____________ __________ ___________ ______________________________ _____________ __________ ___________
17. Does the Applicant design, manufacture or test any product or process for
creating a product?
( ) YES ( ) NO If YES,
provide details on a separate sheet.
18. Does, the Applicant use a written contract with clients? ( ) in all cases
( ) sometimes ( ) Never
19. Has the Applicant or independent contractor ever been dismissed from a project of a
contract prior
to completion?( ) YES ( ) NO
If YES, please provide details on a separate sheet.
20. Has the Applicant ever entered into contracts where fees were obtained by the client
achieving
certain cost reductions or results in general?
( ) YES ( ) NO (if YES, please attach explanation).
21. Does any director, officer, employee, partner or independent/sub contractor of the
Applicant
serve on the Board of directors of any client or own any
financial or equity interest in any client
of the Applicant ( ) YES ( ) NO If YES,
please attach an explanation.
SECTION III -CLAIMS INFORMATION
Do not complete this section if this is an
application for a renewal policy at the same limit of liability
with one of the USLI Companies.
22. During the past (5) five years, has any claim been made or suit brought against the
agency, its
predecessor(s) in business, or any of its present or former
owners, partners, officers, directors,
employees, or independent/sub Contractors? ( )
YES ( ) NO (IF YES, PLEASE PROVIDE
DETAILS ON THE SEPARATE SUPPLEMENTAL CLAIMS APPLICATION.)
23. Is any owner, partner, officer, director, employee, or independent/sub contractor
aware of any
circumstance, allegation, contention, or incident which may
result in a claim being made against
the agency, its predecessor(s) in a business, or any of its
present or former partners, owners,
officers, directors, employees, or independent contractors?
( ) YES ( ) NO (If YES, PLEASE
PROVIDED DETAILS ON THE SEPARATE SUPPLEMENTAL CLAIMS FORM)
SECTION V - PROFESSIONAL LIABILITY INSURANCE COVERAGE
24. Has any Policy of or Application for professional liability insurance on your behalf
or on the behalf of
any of your principals, officers, employees, or on behalf of any
predecessors in business ever been
declined, canceled, or renewal refused? ( ) YES
( ) NO If yes, advise
details____________________________________________________________________
25. Is similar professional liability insurance currently in force? ( ) YES
( ) NO if Yes, please advise:
| Name of Carrier | Limit | Deductible | Premium | Policy Period |
| ________________________ | _________ | ___________ | ______________ | ______________ |
Retroactive Date (if
any):_________________________________________________________________________
Length of time coverage has continuously been in
force:____________________________________________________
SECTION V - GENERAL LIABILITY INFORMATION
26. Does the Applicant currently have General Liability Insurance? ( ) YES
( ) NO If Yes, please
advise the following:
| Carrier | Premium | Expiration Date | GL Losses |
| _________________ | ___________________ | __________________ | ( ) YES ( ) NO |
Describe any General Liability Losses in past 5
years:__________________________________________________
__________________________________________________________________________________________
END OF PAGE 2
27. Number of Employed Consultants
_________________________________________
28. (a) Does the Applicant use Independent Contractors? ( ) YES ( ) NO
If Yes, Please answer
28 (b) and (c).
(b) Is General Liability coverage to include Independent
Contractors? ( ) YES ( ) NO
(c) Number of Independent Contractor Consultants used
____________________________________________
29. (a) Is the Applicant involved in the installation of equipment or physical application
of the items for
which they are
providing consultation services (including work done by independent contractors
supplied by the
Applicant)? ( ) YES ( ) NO if YES, please
answer 29(b) and (c) below:
(b) Describe installations or
applications: _________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
30. Additional Insureds to be included (List name, address and relationships to
Applicant):_________________________
__________________________________________________________________________________________
SECTION VI - PERSONAL PROPERTY INSURANCE INFORMATION
31. (a) Personal Property Limit Needed (at 80% Coinsurance/Replacement
Cost)___________________________
If Limit is greater than $25,000 please answer 31 (b) and (c) below:
(b) Protection Class (1 through 10)
_____________________________________________________
(c) Burglar Alarm ( ) YES ( ) NO
Central Station ( ) YES ( ) NO
Sprinklers
( ) YES ( ) NO
Central Station ( ) YES ( ) NO
Fire Alarm
( ) YES ( ) NO Central
Station ( ) YES ( ) NO
32. If located in first tier coastal county, distance from water (ocean, bay, or
inlet)_____________________
33. Previous Carrier: ________________________ Expiration Date: ______________ Premium
$______
34. Property Claims Paid or Pending during last 5 years (by year)
_________________________________
________________________________________________________________________________
SECTION VII - REQUIRED INFORMATION
Please Submit each of the following items with the Submission
A. USLI Application.
B. Copy of Financial Statement.
C. Copy of Applicant's formalized standard client contract.
D. Copy of resumes on technical and key personnel.
E. Marketing materials/brochures.
| FRAUD STATEMENT: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO
DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON, FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT WHICH IS A CRIME AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION. |
| THE STATES OF NEW YORK AND FLORIDA REQUIRES THAT WE HAVE THE NAME
AND ADDRESS OF YOUR (INSURED'S) AUTHORIZED AGENT OR BROKER NAME OF AUTHORIZED AGENT OR BROKER_____________________________________________________________________________________________ ADDRESS___________________________________________________________________________________________________________________________ LICENSE NO. ________________________________________________________________________________________________________________________ MAIL COMPLETED APPLICATION THROUGH LOCAL AGENT OR BROKER TO: |
|
NOTICE TO THE APPLICANT The undersigned declares that to the best of his/her knowledge and belief the statements set forth herein are true. the undersigned further declares that nay occurrence or event taking place prior to the effective date of the insurance applied for which may render inaccurate, untrue ,or incomplete any statement made will immediately be reported in writing to the Insurer and the Insurer may withdraw or modify any out- standing quotations and/or authorization or agreement to bind the insurance. TheInsurer is hereby authorized, but not required, to make an investigation and inquiry in connection with the information, state- ments and disclosures provided in this Application. The decision of the Insurer not to make or to limit any investigation, or inquiry shall not stop the Insurer from relying on any statement in the Application. The signing of this Application does not bind the undersigned to purchase the insurance, nor does the review of this Application bind the insurance company to issue a policy. It is understood the Insurer is relying on this Application in the event the Policy is issued, it is agreed that this application shall be the basis of the contract should a policy be issued and it will be attached and become part of this policy. Signature of Applicant or Insured:_______________________________________ Date:_____________ Must be signed by a Principal, Partner, or Officer of the Firm |
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tel: 800-447-4180 | fax: 732-223-9072
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tel: 800-447-4180 | fax:
732-223-9072
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