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Miscellaneous Professional Liability Application
General Information
1.
Company Name(Applicant)
Street Address
City
State
Zip
Business Phone
Cell
Fax
Email Address
Website
2.
Please list the states in which the Applicant provides service:
Year Established
3.
Please provide a brief description of the professional services for which coverage is desired:
Revenue Breakdown
4.
Please list the professional services that the Applicant provides and the percentage of revenue generated by each service:
Professional Service
Percentage of Revenue (%)
Description of Business
5.
Please indicate the total revenue for the following fiscal years for both the Applicant and any subsidiaries performing professional services sought to be covered under this policy:
Year
Revenue
Current Year
$
Last Year
$
Next Year
$
6.
How many years has the applicant been in business?
7.
Please indicate the Applicant’s total employees.
8.
How many of these employees provide professional services directly to clients?
9.
Does the Applicant provide professional services to any client/customer that represent more than 20% of Applicant’s gross annual income?
YES
NO
10.
Is the Applicant controlled or owned by, or associated or affiliated with or does it own any other firm or business enterprise?
YES
NO
If YES, please explain.
11.
Are any professional services rendered to entities related by ownership to the name insured, its directors, officers and/or employees?
YES
NO
If YES, please explain.
12.
Does the Applicant have a contract in place with Clients?
All of the time
Most of the time
Some of the time
Never
13.
Do the Applicant\’s contracts contain indemnification / hold-harmless clauses running in its favor?
All of the time
Most of the time
Some of the time
Never
14.
Does the Applicant do business through independent contractors?
All of the time
Most of the time
Some of the time
Never
15.
Does the Applicant contractually require independent contractors to maintain E&O Insurance?
All of the time
Most of the time
Some of the time
Never
16.
Have any of the Applicant’s owners, principals, directors, officers or employees ever been the subject of an investigation, disciplinary or criminal action as a result of their professional activities?
YES
NO
If YES, please explain.
17.
Have any professional liability claims ever been made against the Applicant, Applicant’s owners, principals, directors, officers or employees?
YES
NO
If YES, please describe, including name of claimant, type of service provided and allegation made, date claim was made, demand amount and final deposition including indemnity and expense amounts.
18.
Does the Applicant or do the Applicant’s owners, principals, directors, officers or employees have any knowledge or information of any act, error or omission which might reasonably give rise to a claim against any potential insured or its predecessors in business?
YES
NO
REAL ESTATE AGENTS ONLY
Describe all professional services performed for others and indicate the percentage of gross revenues derived from each activity.
Percentage
Asset Management
%
Broker Price Opinions (if not in combination with another listed service)
%
Business Brokerage
%
Business Valuation
%
Commercial/Industrial Property Management
%
Commercial/Industrial Real Estate Agent or Broker
Provide the following for commercial properties sold in the past twelve (12) months:
Number of Transactions
Average Property Value
$
Highest Property Value
$
Loan Modification (if not done as a mortgage broker)
%
Mortgage Broker
%
Residential Real Estate Agent or Broker
%
Provide the following for residential properties sold in the past twelve (12) months:
Number of Transactions
Average Property Value
Average Property Value
$
Highest Property Value
$
Residential Property Management
%
Provide the percentage of management fees derived from each of the following:
Apartment
%
Home Owners Association
%
Condo/ Coop
%
Timeshare
%
Other
%
Real Estate Appraisal
%
Real Estate or Construction Consultant
%
Describe:
Real Estate Development:
%
Real Estate Leasing Agent
%
Other (specify):
REAL ESTATE AGENTS ONLY
1.
Does the Applicant use:
A Home Protection or Warranty Program?
YES
NO
If YES, what percentage of units sold includes such programs?
%
An in-house office policy/procedures manual?
YES
NO
2.
Has the Applicant ever been the subject of any disciplinary action by a regulatory agency resulting from the violation of any federal, state or local fair housing law?
YES
NO
If YES, attach a separate page detailing the action(s), the result(s) and steps taken to mitigate future disciplinary actions?
3.
Does the Applicant and/or any of its subsidiaries and/or affiliates form, manage or organize group investments/syndications (i.e., limited partnerships general partnerships, corporations, REITs, etc…) for the purpose of investing in real property?
YES
NO
If YES, Provide details:
Percentage of real estate or property management services provided to properties for which the Applicant has formed an investment vehicle.
%
4.
Does the Applicant engage in or own or control any organization that engages in:
Title searching, abstracting, escrow or closing services?
YES
NO
If YES, Provide details:
Any construction management, construction consulting, property preservation or real estate development?
YES
NO
If YES, Provide details:
5.
Does the Applicant, any of its subsidiaries and/or affiliates build, repair or maintain property?
YES
NO
If YES, Provide details:
6.
Does the Applicant or any principal, partner, officer, director, employee, independent contractor, or manager acquire properties for the purpose of resale, including acquisition under a Guaranteed Sales Contract?
YES
NO
If YES, Provide details:
7.
Does the Applicant have an exclusive listing agreement with any builder or development organization?
YES
NO
If YES, Provide details:
Current E&O Carrier:
Limits:
Deductible:
Premium:
Signature:
Phone:
Date:
Name/Title:
E-mail:
