Welcome to
Professional Liability EZ-App from A&M.
For fast service on your commercial
accounts complete the form below and hit the "Step Two" button. Your submission
will be electronically delivered to the next available Commercial Lines Underwriter.
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Producer Name:
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Producer Code:
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Producer Phone Number:
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Producer Fax Number:
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E-mail Address:
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Agency Contact Name:
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Insured Name:
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Insured's Address:
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Insured Web Site Address:
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Number of Employees:
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Full-time
Part-time
Seasonal
Total
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Business is a:
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Date Established (MM/DD/YYYY):
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Describe in detail all the professional services and indicate the percentage of
gross revenues derived from each activity:
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Estimated Annual Revenue:
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$
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Annual Gross Revenues for the last three years:
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Were more than 50% of the Applicant's revenue derived
fron one client?
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If Yes, specify client and description of services rendered:
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Does the Applicant utilize the services of independent contractors
or sub-consultants?
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If Yes, indicate percentage of billings and whether a certificate of Professional
Liability is required of each:
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Does the Applicant build, service, repair, install, manufacture
or fabricate anything??
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Does the Applicant sell any product other than computer
software?
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Does the Applicant carry General Liability Insurance?
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Insurer:
Limits:
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Is a Professional Liability (E&O) insurance currently
in force?
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If Yes, provide information regarding coverage during the past five (5) years:
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During the last five years, have there been any professional
liability claims against the Applicant proposed for this insurance?
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If Yes, please provide loss runs.
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Is (are) any person(s) or entity(ies) aware of any fact,
circumstance or situation which might afford grounds for any claim, such as would
fall under the proposed insurance?
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If Yes, please provide details.
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Has any insurer cancelled, rescinded, non-renewed or declined
any similar insurance for the Applicant proposed for this insurance in the last
five years?
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If Yes, attach a copy of such insurer's notice.
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During the past five years has the Applicant been named
as a Defendant or Plaintiff in a lawsuit?
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If Yes, please supply full details.
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Limits of Liability Desired:
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Deductible Desired:
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(You will get a summary page to
review before submitting)
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