Effective Date

Aggregate Limit

Per Claim Limit

Aggregate Retention

Per Claim Retention

Retroactive Date

Business name

Insured contact's name

Email address

Phone number

City

Country

Line 1

Line 2

Line 3

Organization

Postal code

State

Total annual revenue

Years of operation

Does the business have a website or domain?

Do you have a website or domain?

Industry classification

Does the applicant offer any additional professional services not represented by their selected industry classification?

Do you offer any additional professional services not represented by your selected industry classification?

What is the applicant's estimated number of years of experience in their industry?

What is your estimated number of years of experience in your industry?

Does the applicant use a written contract, service agreement, or letter of engagement with clients?

Do you use a written contract, service agreement, or letter of engagement with clients?

Does the applicant have any Continuing Education required for all employees?

Do you have any Continuing Education required for all employees?

In the last 5 years, has the applicant, or its predecessors, subsidiaries, or affiliates experienced any incidents, losses, or been the subject of any claim that would fall within the scope of a professional liability insurance policy for which the applicant is applying?

In the last 5 years, have you or your predecessors, subsidiaries, or affiliates experienced any incidents, losses, or been the subject of any claim that would fall within the scope of a professional liability insurance policy for which you are applying?

During the last 3 years, has the applicant been the subject of an investigation or action by any regulatory or administrative agency for privacy related violations?

During the last 3 years, have you been the subject of an investigation or action by any regulatory or administrative agency for privacy related violations?

Is the applicant aware of any fact, circumstance, situation, allegation, or incident that could reasonably give rise to a claim, loss, or any legal or regulatory action against them that would fall within the scope of a professional liability insurance policy for which the applicant is applying?

Are you aware of any fact, circumstance, situation, allegation, or incident that could reasonably give rise to a claim, loss, or any legal or regulatory action against them that would fall within the scope of a professional liability insurance policy for which you are applying?

Has the insurer cancelled, rescinded, non-renewed, or declined similar professional liability insurance coverage for the applicant (or its predecessors, subsidiaries, and affiliates proposed for this insurance) in the last five years?

Has the insurer cancelled, rescinded, non-renewed, or declined similar professional liability insurance coverage for you (or your predecessors, subsidiaries, and affiliates proposed for this insurance) in the last five years?

Does the applicant currently have professional liability coverage in place?

Do you currently have professional liability coverage in place?

Is the applicant seeking coverage for an affiliated entity, which is not a subsidiary?

Are you seeking coverage for an affiliated entity, which is not a subsidiary?