CKSPECIALTY INSURANCE ASSOCIATES, INC.
APPLICATION FOR
MISCELLANEOUS PROFESSIONAL LIABILITY INSURANCE CA
THIS APPLICATION IS FOR A CLAIMS MADE INSURANCE POLICY
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Name of Applicant:
Address:
Please describe in detail the nature and types of professional services the Applicant is engaged in and indicate the percentage of revenue derived from each.
Type Percentage Nature/Details
- Adjusters %
- Advertising Agents %
- Appraisers %
- Auctioneers %
- Commercial Printers %
- Company Management Consultants %
- Computer Consultants %
- County Clerks %
- Court Reporters %
- Credit Bureau %
- Custom House %
- Electrical Consultants %
- Employment Agencies %
- Escrow Agents %
- Market Research Consultants %
- Process Servers %
- Public Relations Consultants %
- Public Notary %
- Real Estate Operations Managers %
- Shipping and Forwarding Agents %
- Telephone Answering Services %
- Title Agents %
- Title Abstractors %
- Translators %
- Traffic Consultants %
- Travel Agents %
- Urban Planners %
Other classes available on a submit basis.    
Please indicate type of company:
Sole Trader  Partnership  Corporation  Privately Held  Non-Profit  Publicly Traded  Other
Date established:
Is the Application controlled or owned by, or associated or affiliated with, or does it own, any other firm or business enterprise?
Yes  No
If Yes, please explain:
Total Number of staff:
Please provide the following:
Name of Principals
Professional Qualifications
Years in practice
Years with Applicant
Please list Professional Associations to which the Applicant belongs:
Gross billings: This year (est.): Last year: Year prior:
Does the Applicant use a written contract: Always  Sometimes  Never
If not always, please explain how the scope of services to be provided is agreed:
Does the Applicant sub-contract work to others: Yes  No 
If yes, please explain and include any details of any hold harmless agreements, etc:
Is any errors or omissions or professional liability insurance currently in place? Yes  No
If Yes, how long has continuous professional liablity insurance been in place?
If no, the coverage if issued will not cover any of the applicant's prior acts.
If yes, please provide details of such coverage carried for each of the past three years:
Carrier
Period
Limit
Deductible
Premium
Retro Date
Have any claims been made during the past 10 years against the Applicant? Yes  No
If yes, please provide details.
Is the Applicant aware, after enquiry, of any circumstances, which may result in any claims being made against the Assured.
Yes  No
If yes, please provide full details:
Has any insurer cancelled or refused to renew any similar insurance during the past ten years? Yes  No
If yes, please provide full details:
Limit Requested:
 
$250,000 $500,000 $1,000,000
THE APPLICANT DECLARS THAT THE ABOVE STATEMENTS AND REPRESENTATIONS ARE
TRUE AND CORRECT AND THAT NO FACTS HAVE BEEN SUPPRESSED OR MISSTATED.
THE COMPLETION OF THIS APPLICATION DOES NOT BIND THE APPLICANT TO BUY OR THE
COMPANY TO ISSUE THE INSURANCE, BUT IT IS AGREED THAT THIS APPLICATION SHALL BE
THE BASIS OF THE CONTRACT SHOULD A POLICY BE ISSUED, AND IT WILL BE ATTACHED AND MADE PART OF THE POLICY.
DATE: APPLICANT'S SIGNATURE:
  x__________________________________________
PRODUCER: TITLE: