Professional Liability Insurance Application
Applicant Information
Full Name
Business Name
Business Address
Phone Number
Email Address
Business Details
Profession/Type of Business
Years in Business
Number of Employees
Estimated Annual Revenue
Description of Professional Services
Locations of Services Offered
Current Insurance Information
Current Insurer (if any)
Policy Expiration Date
Current Coverage Limit
Any Claims in Last 5 Years?
No
Yes
If yes, please provide details
Coverage Requested
Requested Liability Limit
Requested Policy Start Date
Additional Information or Comments