Class Act Insurance Services

Professional Liability
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Professional Liability- This type insurance provides protection against claims that the policyholder becomes legally obligated to pay as a result of an Error or Omission in his\hers professional work. This type of policy DOES NOT cover General Liability Insurance. If you require General Liability Insurance Click Here.

Reason for insurance request:
New in business Currently in business with no prior insurance
They are Cancelling my Account Account is going to Non-Renew Searching for a better price

Applicant Firm’s Name:

Name of Contact Person:

Proposed Effective Date:

Mailing Address:

Home Telephone:

Work Telephone:

Fax Telephone:

Email Address:

Type of Profession:

Accountants Architects & Engineers Appraisers Biotech Companies Certification Risks Claims Adjusters Collection Agents Computer Related Risks Doctors EMT's	Economic Consultants Environmental Consultants Geotechnical Companies High Tech Companies Human Resources Information Technology Insurance Agents Investment Advisors Lawyers Mortgage Brokers/Bankers	Publishers Realtors Safety Consultants Standards Setting Orgs. Temporary Agencies Web Developers Websites - Content Other:
Please describe in detail you profession:

Business entity:

Year business started:

Number of Employees: Full time(Include Self)

Number of Employees: Part time

General Information and underwriting questions

1. Is the applicant a subsidiary of another entity of does the applicant have any subsidiaries?	Yes	No
2. any policy of coverage declined, cancelled or non-renewed during the past 3 years?	Yes	No
3. Any bankruptcies , tax or credit liens against the applicant in the past 5 years?	Yes	No
4. Has the business been placed in a trust?	Yes	No

Please explain any Yes answers:

Prior Carrier Information

Professional Liability None
Carrier:	Policy #	Effective Date:

Limits
Deductible
Retroactive-date
Policy Period
Total Premium

****IMPORTANT DOCUMENTS REQUIRED: For existing businesses you will need to request 4 years of LOSS RUNS from your current insurance provider.
Please fax the LOSS RUNS to 619-584-7407. Insurance companies may take up to ten days to provide you with this information****

Check this box if you have NO losses in the last 4 years:
Lost history information: Please list dates, description of claim, amount paid, and claim status.

Liability Coverage Requested

Limits
Deductible

Additional Interest/Certificate Receipt

Additional Insured | Loss payee | Mortgagee | Lien holder | Employee as Lessor

Name and Address

Please let us know the best time to contact you:

IMPORTANT NOTE: This form is provided as a convenience to you. We will make a good faith effort to obtain competitive quotes for your review. Depending on the type of business, we may require more information and will contact you if necessary. Your submission of this form DOES NOT guarantee that any binding offers will be forthcoming from insurers we represent.