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
*
Alabama
Alaska
American Samoa
Arizona
Arkansas
CW Northern Mariana Islands
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Phillippine Islands
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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