professional liability

Professional liability insurance protects against claims arising from your acts, errors or omissions in rendering services of a professional nature. Businesses involved in everything from advertising to engineering need to consider this coverage seriously. In fact, many corporate users of services such as those provided by engineers often require that insurance be in place before contracting with the professional.

Policies typically include coverage for defense costs, even if a suit proves to have no merit. The policy premium is typically based on the profession involved, the number of professionals covered, annual revenues, location of the business, the limit of liability and the deductible

professional liability QUOTATION REQUEST FORM

REMINDER - Fields marked with an asterisk( * ) require a response.

Contact Information

Contact Person's Name:*

Telephone #, including area code:*

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Fax #, including area code:*

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E-Mail address:*

Business Name:*

Business Address:*

Business Address (other; e.g., suite)

City, State, and Zip Code of business:*

Business Information

Please complete the following information about the owners of your company: *

Owner #1 Name Title

% Ownership Education

Owner #2 Name Title

% Ownership Education

Owner #3 Name Title

% Ownership Education

Owner #4 Name Title

% Ownership Education

Provide either a Federal Employer Identification Number for your business, or your social security number:*

What is the professional practice of the business (i.e., Real Estate, law, Engineering, Medical, Consulting etc.)? *

Does the business specialize within this field of practice (i.e., Commercial Leases, Taxation, Computer Hardware or Software Engineering, OB GYN, Software Development consulting etc.)?*

Yes No

Please provide a brief description of your practice and your area of specialty?*

Please provide professional certifications of owners, where applicable: *

Does the business belong to any professional organization, society or association?*

Yes No

If Yes, please list them. *

Does the business have a website?*

Yes No

If Yes, please provide the website address: *

Prior Coverage Information

Does your business currently have professional liability? *

Yes No

If yes, please provide the following information:*

Number of years of continuous prior insurance: *

Name of current insurer: *

Effective Date of the Policy: *

Expiration Date of the Policy: *

Retroactive date of current policy (if applicable): *

Desired deductible per claim (Aggregate): *

Limit of Liability coverage (Per claim): *

Limit of Liability coverage (Aggregate): *

Have you ever had a professional liability policy cancelled? *

Yes No

Has your license ever been restricted, suspended, cancelled, or denied? *

Yes No

Have you ever been the subject of a consumer complaint that resulted in a legal or administrative proceeding? *

Yes No

If yes, please provide the following information: *

Name of insurance company

Reasons for cancellation

Date policy was cancelled

Company:

Reason:

Date:

Professional Liability Claims Information

Has your business ever had a Professional Liability claim made against it? *

Yes No

If yes, please provide the following information:

Claim #1:

Approximate date of claim
Approximate amount paid on the claim
A brief description of the claim
Whether the claim is open or closed

Claim Date:
Claim Amount:
Description:
Claim Status: Open Closed

Claim #2:

Approximate date of claim
Approximate amount paid on the claim
A brief description of the claim
Whether the claim is open or closed

Claim Date:
Claim Amount:
Description:
Claim Status: Open Closed

Claim #3:

Approximate date of claim
Approximate amount paid on the claim
A brief description of the claim
Whether the claim is open or closed

Claim Date:
Claim Amount:
Description:
Claim Status: Open Closed

Claim #4:

Approximate date of claim
Approximate amount paid on the claim
A brief description of the claim
Whether the claim is open or closed

Claim Date:
Claim Amount:
Description:
Claim Status: Open Closed

If you would like to explain your claim, or provide us with any other information about your business that would be helpful in obtaining the best possible quote, please feel free to do so in the remarks section.

Congratulations. You have reached the end of our form. If you'd like to submit a comment, provide an explanation of any information you've provided on this form, or give information on additional coverage needed, please do so in the space below. We also invite you to contact us by telephone or fax with more information about your business or your insurance needs.

After you have entered all relevant comments, please click the submit button. Thank you for completing this form, we'll do our best to provide you with a timely quote.

professional liability