Poulton Associates, Inc. :: Insurance Risk Management

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E&O Liability Insurance for Business

Insurance Application Form

To get a free quote on errors & omissions insurance coverage use this application to provide us with the information we will need. Please contact us if you have questions.

Instructions:

Please answer all questions. If any question does not apply, please explain why not. We may request additional information. In the places that request explanations, press <Enter> to scroll down for more space if necessary. If on any question you prefer to fax us the response rather than typing it, please feel free to do that. Our fax number is (801) 268-2674.

Information on your application will be electronically encrypted for confidentiality and security.

Fill in the form, return it, and we'll provide your free quote!

Section 1: Proposed Insured (Applicant)

Your Name:
E-mail Address:
Name of your firm:
Street Address:

City:
State:
Zip:
Phone:
Fax:
Where did you hear about us?
Date your firm was established: (MM/DD/YYYY)
Where is your firm licensed or registered?

Is your firm a:
Corporation Sole Proprietorship
Partnership Other

Is coverage desired for any subsidiary(ies), affiliates, branch offices or other related entities?
Yes No

If yes, please enter the following information: Name, city, state, date established and the relationship to you including percentage of ownership, if applicable.

All remaining questions on this application apply to the persons and/or firms for which coverage is being requested.

In the past five years has the name of your firm been changed and/or had your business been reorganized or restructured?
Yes No

If yes, please provide details:

Within the past five years, have you acquired any business, or have you merged or consolidated with any entity?
Yes No

If yes, please provide the name of entity, date and type of transaction (acquisition, merger or consolidation; press

In any of the transactions listed above, did you assume the liabilities (i.e., responsibility for prior acts) of the acquired merged, or consolidated entity?
Yes No

If yes, please provide details of the liability(ies) assumed

Provide the number of your:
Partners or Officers
Technical Personnel
Clerical Personnel

List the qualifications of key personnel in the space below or fax us the experience resumes of each (801-268-2674): 500 char max

Section 2: Operations

Briefly describe the nature of your business (i.e., types of services performed). Attach a narrative description, if necessary. (As with all of these explanations, You may simply fax us this information if you prefer--801/268-2674.) 500 char max

Briefly describe your five largest jobs or projects during the past five years including the type of service performed and the revenues generated from each. 500 char max

For what types of claims or exposures are you requesting coverage? 500 char max

What safeguards or procedures do you employ to avoid those claims or reduce those exposures? 500 char max

Do you use a written contract or agreement describing the services you will provide?
Yes No

If yes , please fax a copy of this contract to us at (801) 268-2674.

If no , please explain how you reach agreement with your client regarding the services to be rendered. 500 char max

Do all contracts contain a hold harmless or indemnity agreement inuring to your benefit?
Yes No

If no, please explain those circumstances. 500 char max

Do any of your contracts contain guarantees or warranties?
Yes No

If yes, explain the nature of the guarantee or warranty. 500 char max

Have your contracts and procedures been reviewed by a law firm experienced in your field?
Yes No

If no, please explain why they have not. 500 char max

Please provide the following information regarding your income:
Domestic Operations:
Past 12 Months:	$
Current 12 Months:	$
Estimate for coming year:	$
Basis: Gross Billings Fees Commissions Sales
Is your income contingent upon generating savings or earnings for your clients? Yes No
If yes, please describe the nature of those contingencies in detail: 500 char max

Section 3: Claim Experience
Have any claims, suits, or proceedings been made during the past five years against any of you or any of your predecessors in business, subsidiaries, or affiliates or against any of their past or present partners, owners, officers, sales persons or employees? Yes No
If yes, please describe the nature of those contingencies in detail: 1000 char max

The policy for which you are applying, if issued, will not insure any claims, suits, or proceedings made against any of you before the inception date of the policy or any subsequent claims, suits, or proceedings arising there from.
Are any of you aware of any actual or alleged fact, circumstance, situation, error or omission which may reasonably be expected to result in a claim being made against you or any of the persons or entities described in the preceding question? Yes No
If yes, please explain: 1000 char max

Have any of you or any of your predecessors in business, subsidiaries, or affiliates or any of their past or present partners, owners, officers, sales persons, or employees been investigated and/or cited by any regulatory agency for violations arising out of your or their activities? Yes No
If yes, please give details: 1000 char max

Section 4: Prior or Current Coverage

Provide the indicated information for similar insurance, if any, carried during the last five years. Include any coverage which may be directly related or respond in part to the exposure for which you are applying for coverage under this application:

Company / Limit / Deductible / Premium / Policy Term 500 char max

Has any application for similar insurance made on behalf of any of you or any of your predecessors in business or their present partners, owners, officers, sales personnel, or employees ever been declined or has any such insurance ever been canceled or refused renewal? (Not applicable in Missouri)
Yes No

If yes, please give details: 1000 char max

Provide the following information for General Liability coverage currently in force:
Company:
Limit:	$
Deductible:	$
Policy Term:
Does the policy above include coverage for Products/Completed Operations Hazards? Yes No

Section 5: Proposed Description of Services

In this section you are being asked to describe the services you want to insure as you would like them to appear on the policy under "Schedule of Insured Services". Your suggested wording will be considered by us, but it is subject to change based on underwriting requirements or may be further negotiated. Your proposed wording is not an insuring agreement.

Proposed Schedule of Insured Services: 1000 char max

Limit of Liability desired	$
Deductible:	$
Other Comments
Are there any other kinds of insurance you need (e.g., Directors & Officers, Employee Dishonesty, etc.)? Please list them, along with any comments or questions you may have. We would especially like your feedback on this form's ease of use. 1000 char max

The End of the Form
(You're finally finished!)

Now make your efforts worthwhile by reading the next section and clicking on the submit button--to get your free quote! (You may want to print a copy of this completed form first.)

Representations

By submitting this application, you agree that:

A.	The statements and answers given in this application and any attachments to it are accurate and complete;
B.	The statements and answers you furnished to us are representations you make to us on behalf of all persons and entities proposed for coverage;
C.	Those representations are a material inducement to us to provide a proposal for insurance;
D.	Any policy we issue will be issued in reliance upon those representations;
E.	You will report to us immediately, in writing, any material change in your operations, condition or answers provided in this application that occur or are discovered between the date of this application and the effective date of any policy, if issued; and
F.	Upon receipt of any such notice, we reserve the right to modify or withdraw any proposal for insurance we have offered.