INDICATION INFORMATION
 
 
 
 
 
 
Not available for accounts with losses in the past five years. If there is loss history, please complete the section below and submit details in a claim supplement.
 
 
 
 
Section 1 - About Your Business
 
 
 
 
Applicant First Name*
 
 
Applicant Last Name*
 
 
 
Agency Name*
 
 
 
 
Your Website Address
 
 
 
 
Location Address*
 
 
City*
 
 
 
State*
 
 
ZIP Code*
 
 
 
Same as Mailing Address
 
 
 
If Not, What is Your Mailing Address?
 
 
 
 
 
 
Email Address of Primary Contact*
 
 
Phone*
 
 
 
 
 
 
Description of Operations*
 
 
 
 
 
 
Date Established
 
 
 
 
 
 
 
List 12 Month Gross Receipts Below
 
 
 
 
Revenue Last Year
 
 
Revenue Current Year (Based on 12 Months)
 
 
 
Revenue Forecast for Next Year
 
 
 
 
 
 
 
(a) Number of principals, partners, officers and professional employees directly engaged in providing services to clients
 
 
 
 
(b) Number of Independent/subcontractors
 
 
 
 
 
 
 
Does the Applicant provide services not disclosed above?*
 
Yes
No
 
 
 
If Yes, please detail additional services
 
 
 
 
 
 
Section 2 - About Your Policy
 
 
 
 
Upload your current declarations page. If you do not have a declarations page but have current coverage, please complete Section 2.
 
 
 
Desired Limits
 
 
 
 
Desired Effective Date (mm/dd/yyyy)
 
 
 
 
Professional Liability Insurance Carrier
 
 
 
Effective Date (mm/dd/yyyy)
 
 
Retro Date (mm/dd/yyyy)
 
 
 
Limits
 
 
Deductible
 
 
 
Premium
 
 
 
 
Association Referral
 
 
Agency