Miscellaneous Professional Liability

Errors and Omissions Insurance Form

Complete and submit your application for E&O insurance online.

Mandatory Fields are marked with an asterisk *. (If a manadatory field does not apply to you enter "na".)

* Name of Applicant

Head Office

* Address

* City

* Province

* Postal Code

Branch Office (if applicable)

Address

City

Province

Postal Code

* Date Established:

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* Phone: Ext: Fax:

Web Site Address:

* Business Type:

select

Provide a clear and detailed description of the Professional activities that you undertake.

Fees

Previous 12 Mo.

Start Date:

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End Date:

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$ Amount:

Expiring 12 Mo.

Start Date:

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End Date:

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$ Amount:

Projected 12 Mo.

Start Date:

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End Date:

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$ Amount:

State the Professional services performed or expected to be performed by the applicant indicating the approximate percentage of total fees derived from each category.

Category 1: Category 1 %: Category 2: Category 2 %: Category 3: Category 3 %: Category 4: Category 4 %:

What percentage of the applicant's work involves sub-contracting of work to others?

What type of work is sub-contracted?

What percentage of the applicant's fees will be earned:

In the U.S.A
Overseas

For work outside of Canada, please provide details with respect to the location, type of work and fees for each project.

Total Number of:

Partners & Officers:

Employed Professionals:

Other:

Attatch Partner Resumes:

Explain fully the educational requirements of your profession.

Does the applicant belong to any related associations? (If YES, please indicate such memberships.)

select

Are there any prerequisites for association eligibility? (If Yes, please provide details.)

select

Is there legislation currently in force governing the practice of the applicant?

select

10.

Is the applicant controlled by, owned by, or related to any other firm, corporation or company? (If Yes, please provide details.)

select

11.

Do any of the partners or officers of the Applicant hold an interest in any other corporation with whom the Applicant carries on business? (If Yes, please provide details.)

select

12.

Does the applicant firm use a written contract with clients?

select

Please Attatch Standard Contact

13.

Please list your five largest projects done during the past five years.

14.

Are more than 25% of your Professional Services provided for one client? (If Yes, please provide details.)

select

15.

Does the Applicant currently carry professional or errors and omissions liability insurance?

select

If Yes, please to the question above please provide the following:

Name of the Insurer:

Please indicate if such coverage is offered on an occurrence basis or claims made basis.

select

If current coverage is on a claims made basis, what is the retroactive date?

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What is your current policy limit?

What is your current deductible?

If you are presently insured, are renewal terms being offered?

select

If No, please state reason:

16. a)

* Have any claims ever been made to the knowledge of the Applicant against the Applicant, any business predecessors, or any of the present or former partners or officers?

select

16. b)

* Is the Applicant aware of any act, error, omission or circumstances which could give rise to a claim against the Applicant or any predecessor in business, or any present or former partner or officer?

select

IF THE ANSWER TO EITHER 16 a) or 16 b) IS YES, COMPLETE THE CLAIMS HISTORY SECTION AT THE END OF THIS FORM

NOTE: THE POLICY DOES NOT COVER ANY CLAIM OR CIRCUMSTANCE STATED IN 16 a) or 16 b) OR ANY ACT, ERROR, OMISSION OR CIRCUMSTANCE WHICH COULD GIVE RISE TO A CLAIM, OF WHICH THE APPLICANT HAS KNOWLEDGE PRIOR TO THE INCEPTION OF THE POLICY.

17.

* Has any Partner, Executive Officer, Director or Professional Employee had their licence suspended, been fined or reprimanded during the past five years? (If Yes, please provide details.)

select

18.

* To the Applicant's knowledge, has any company declined or terminated the insurance for the Applicant, any present partner of officer or for any predecessor in the business, past partners or officers? (If Yes, please provide details.)

select

19.

Limits

* Insurance required:

select

Deductible

select

20.

When is your fiscal year end?

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We hereby declare that the above statements and particulars are true and that we have not suppressed or misstated any material facts and we agree that this declaration shall be the basis of any binder or contract or insurance with the Insurer, and that the limits and deductibles as stated in the said binder or contract of insurance shall govern.

It is understood and agreed that the completion of this application does not bind the Insurer to the issue of the insurance nor the Applicant to the purchase of the insurance.

It is further understood and agreed that if, following submission of this application to the Insurer and prior to the date requested for coverage to be effective, the Applicant becomes aware of any information which has a bearing on question 16 a) or 16 b) of this application, the Insurer shall be immediately notified in writing of such information.