Professional Liability (E&O) Insurance Application for Consultants
1. Applicant Details
Full Legal Name of Applicant (including all subsidiaries):
Address:
Telephone:
Website:
Years in Business:
Legal Structure:
Sole Proprietorship
Partnership
Corporation
LLC
Other
2. Professional Services
Describe professional consulting services provided:
Estimated annual gross revenue:
Percentage of services by client industry (list):
Territory of operation:
3. Claims & Insurance History
Have claims, suits or legal proceedings ever been made against you?
No
Yes
If yes, please provide details:
Have you had professional liability insurance before?
No
Yes
If yes, name of insurer:
Has insurance ever been declined or cancelled?
No
Yes
If yes, give details:
4. Coverage Requested
Limit of Liability Requested:
Deductible:
Requested Effective Date:
5. Additional Information
Number of staff (by role):
Describe any risk control procedures or quality assurance methods in place:
Other information relevant to this application:
6. Declaration
I declare that the statements are true and complete to the best of my knowledge and belief.
Name:
Title:
Signature:
Date: