Errors & Omissions Program Application

Form Highlights:

Please review the policy form and endorsements for coverage provided. Actual coverage may vary and is subject to policy language as issued.

Data Collection Tool

Yes     No

 
Expiring Carrier Expiring Limits Expiring Retention Expiring Retro Date Expiring Premium

If none, limits requested : $250,000 $500,000 $1,000,000


Professional Class Annual Revenue % Revenues from
Residential Service
% Revenues from
Commercial Service
% Revenues from
Other
Septic System Inspection  %  %  %
Septic System Design  %  %  %
Septic System Consulting  %  %  %
Other (Please Specify) *
 %  %  %
Total Revenues $

* Coverage is not extended unless specifically added as a covered profession

Employee Breakdown (for covered services only)

# Full Time Employees # Part Time Employees # Independent Contractors # California employees

Does any single contract contribute more than 50% of total gross revenues?Yes    No
Does the Applicant have a Parent Entity?Yes    No (if Yes, provide name)
Does the proposed insured require coverage for additional insureds?Yes    No (if Yes, provide name)
During the past five years, has the Applicant's Professional Liability coverage been cancelled or non-renewed for a reason other than the insurer withdrawing from a state or no longer providing coverage?Yes    No (if Yes, provide name)

For Applicants without previous coverage, warranty is required

With regards to the coverages for which the Applicant is applying, have any claims been made against any party proposed for coverage within the last 5 years?Yes    No (if Yes, complete supplement)
Is any party proposed for coverage aware of any fact, circumstanc or event which could give rise to a claim?Yes    No (if Yes, complete supplement)

Claims or Circumstances Supplement: For Applicants without previous coverage, warranty is required:
If the answer to the claims made or knowledge was yes, please provide the following information:

  Claim #1 Claim #2 Claim #3
Month/Year claim was made:            
Was coverage forced?
Claimant
Description
Is the claim open or closed? Open Closed Open Closed Open Closed
Total claim amount: $ $ $
Defense Expenses Paid $ $ $
Indemnity Paid $ $ $

 

Are you a member of NOWRA? Yes    No

Other association member (please specify) :


Other Information:

 


Name of Designated Officer

Officer's Email Address

Date
 

 
The Powderhorn Agency, Inc. | P.O. Box 872, Brookfield, CT 06804 | P: 888-354-0677 | www.PowderhornAgency.com
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