Florida Professional Liability / E&O Application | Hendrickson Insurance, Sarasota FL

A. Business Information

Legal / Named Insured *

Required.

DBA (doing business as)

FEIN *

Required to bind. Or check the box.

Website

I don't have my FEIN handy. I will send it before binding.

Contact name *

Required.

Phone *

Required.

Email *

Enter a valid email.

Primary location address *

Required.

City

State

ZIP

Years in business

Years under current ownership

B. Profession & Services

Describe your professional services in detail *

Required.

Professional licenses or certifications held

If services are mixed, percent of revenue by main service

Design Professionals

This is what an A&E underwriter looks at first. Answer for your firm and for anything you subcontract out. Carriers ask both, and leaving out the subcontracted piece is the most common reason a quote stalls.

Which of those areas do you subcontract out, and to whom?

Principal's years of professional experience

Primary discipline

Project types you work on (check all that apply)

% original design

% peer / plan review

% inspection

States where you are licensed / practice

C. Firm Profile

Number of owners or members

Number of W-2 employees, NOT counting owners or subcontractors

Number of licensed professionals

Annual revenue

Highest-value contract in the past 12 months

Percent of work subcontracted

Expected amount you will pay subcontractors in the next 12 months

Where is the work performed? The two numbers should add to 100.

Percent at your office or home office

Percent at client sites or in the field

Office and field percentages need to add up to 100.

What type of contract do you predominantly use?

D. Risk

E. Coverage Requested

Limit requested

$1,000,000 $2,000,000 $5,000,000 Other

Deductible or retention

Coverage basis preference

Claims-made Occurrence Not sure

F. Current & Prior Coverage

Current E&O carrier

Policy number

Policy expiration date

Years continuously insured

Retroactive date on your current policy

The retroactive date is printed on your current declarations page. Carrying it over is what keeps your past work covered.

When did it cancel or expire?

Because there is a gap in coverage, a new policy will start fresh. It will cover work you do after the policy starts.

Which coverage, which carrier, and why?

Which coverage, and when?

G. Claims & Incidents

These are three different questions and carriers treat them very differently. Answer each one on its own.

Date, carrier, description, and amount

Date, who, and what was claimed

What happened, when, and what it cost you to fix

Are you, or any of your business's owners, officers, partners, or employees, aware of any mistakes, damages, accidents, or other circumstances that may lead to a claim against this policy? *

Yes No

Please choose.

Answer yes if anything at all comes to mind. A yes does not stop us from getting you covered. A wrong no can void your policy later.

Tell us what it is, in your own words

H. Acknowledgement

I certify that the information above is true and complete to the best of my knowledge. Submitting this form does not bind coverage; coverage is subject to underwriting approval and payment of premium.

Typed signature (full name) *

Required.

Date *

Required.

I agree to the statement above. *

Please confirm to submit.

Professional liability application.

A. Business Information

B. Profession & Services

Design Professionals

C. Firm Profile

D. Risk

E. Coverage Requested

F. Current & Prior Coverage

G. Claims & Incidents

H. Acknowledgement

Thank you — application received

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