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Tudor iiw insurance services, inc

Insurance Company independent insurance wholesalers, inc.

A Member of the Western World Ins Group 808 SW 3^rd Ave #590 – Portland, Or 97204

(503) 224-1956 fax(503)224-3010

ERRORS AND OMISSIONS LIABILITY APPLICATION

NOTICE: This application is for a CLAIMS MADE POLICY. Except as may be otherwise provided herein,

this coverage is limited to liability for only those claims which are first made against the insured and

reported to the Company during the policy period.

1. Name of Firm ______________________________________________________________________________

Street Address ______________________________________________________________________________

City ___________________________________________ State _____________ Zip _____________________

Website Address _____________________________________________________________________________

2. Date Established _____________________________

3. Is applicant firm a Corporation ________ LLC ________ Partnership ________ Sole Proprietorship ________

4. Is the firm owned by, associated with or controlled by any other business? YES NO

If yes, give details ____________________________________________________________________________

5: Describe in detail the nature of the professional or business activities for which insurance is desired.

___________________________________________________________________________________________

6. How long have you been engaged in your current occupation or business? _______________________________

7. Are you engaged in any other profession or business? YES NO

If Yes, explain _______________________________________________________________________________

8. Provide the number of your staff.

Partners or Officers ___________ Professional/Technical Personnel _____________ Support ______________

9. List the qualifications of professional and/or trade organizations.

___________________________________________________________________________________________

10. List membership in professional and/or trade organizations.

___________________________________________________________________________________________

11. Gross Revenue estimated for next year. Indicate year in spaces provided __________ $ ___________________

Current Year ____________ $ _________________ Previous Year ______________ $ ___________________

12. Are any changes in the nature or size of the applicant’s business anticipated over the next 24 months?

YES NO

13. Does the applicant use independent contractors? YES NO

If Yes, state how many and explain what types of services and what percent of your total receipts are

subcontracted.

____________________________________________________________________________________________

Is evidence of professional liability insurance required from independent contractors? YES NO

What is the limit required? ______________________________________________________________________

14. Does your firm use a written contract or agreement describing the services to be provided? YES NO

15. Have your contracts and procedures been reviewed by a law-firm? YES NO

16. Does your firm assume liability for others under contracts utilized? YES NO

17. List your three largest clients during the past year and indicate services performed and approximate revenue from

each:

Name Services Revenues

___________________________________ ________________________________ _________________

18. Provide details of General Liability insurance in force:

Company Limit Deductible Policy Term

_______________________________ ______________ ________________ _________________

Does the policy detail above include coverage for Products/Completed Operations Hazard? YES NO

19. Please provide details of Errors and Omissions Insurance carried during last three years.

Company Limit Deductible Premium Policy Term

_______________________ ________________ ______________ ______________ _______________

is your expiring policy a CLAIMS MADE POLICY? YES NO

If yes, advise Retroactive Date. _______________________

20. Give an example of a claim that you intend to have insured under this policy.

_________________________________________________________________________________________

21. Has any application for Errors & Omissions or similar insurance made on behalf of you and your firm, or present

partners, owners, officers or employees ever been declined. or has any such insurance ever been canceled or

refused renewal? YES NO

If Yes, give details below or attach an information sheet.

__________________________________________________________________________________________

22. Have any claims, suits or proceedings been made during the past five years against any of you or your firm,

your predecessors in business or against any present partners, owners officers or employees? YES NO

If Yes, give details below or attach an information sheet.

__________________________________________________________________________________________

23. Are any of you aware of any alleged act, circumstance, situation, error or omission which may result in a claim

being made against you or any of the persons or firm described? YES NO

If Yes, give details below or attach an information sheet.

__________________________________________________________________________________________

24. Limit of Liability request ______________________________ Deductible ___________________________

25. Please include with this application the following items:

A. Current brochure or similar item describing activities or services

B. Most recent financial statement or annual report

C. Copies of standard contracts for professional or business activities.

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR

OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY FALSE INFORMATION,

OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT

MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.

I/WE HEREBY DECLARE that the above statements and particulars are true and that I/we have not suppressed or

misstated any material facts and I/we agree that this application shall e the sole basis of any subsequent contract

or insurance with the company. Signature of the application does not bind the Firm or Company to complete the

insurance.

Application must be signed and dated by principal, partner, officer or director of the firm.

____________________________ _______________________________________________________________

Date Signature of Applicant Title

PLEASE NOTE: COMPLETION AND SUBMISSION OF THIS APPLICATION IS FOR THE PURPOSE OF

SECURING A PREMIUM QUOTATION ONLY. NO COVERAGE WILL BE EFFECTED UNTIL RECEIPT

OF WRITTEN INSTRUCTIONS AND PREMIUM PAYMENT. ANY SUBSEQUENT CONTRACT ISSUED

WILL BE IN FULL RELIANCE UPON THE STATEMENTS AND REPRESENTATIONS MADE IN THIS

APPLICATION AND THIS APPLICATION WILL BE MADE A PART OF THE POLICY. A SIGNED

APPLICATION DATED NOT MORE THAN 45 DAYS PRIOR TO THE INCEPTION DATE WILL BE

REQUIRED IN THE EVENT COVERAGE IS EFFECTED.