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License# 0L09546
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Step One: Complete Form
Step Two: Review and Submit
Step Three: Finish
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.
Producer Name:
Producer Code:
Producer Phone Number:
Producer Fax Number:
E-mail Address:
Agency Contact Name:
Insured Name:
Insured's Address:
Insured Web Site Address:
Number of Employees: Full-time  Part-time  Seasonal  Total
Business is a:
Date Established (MM/DD/YYYY):
Describe in detail all the professional services and indicate the percentage of gross revenues derived from each activity:

Estimated Annual Revenue:
Annual Gross Revenues for the last three years:
Year: $
Year: $
Year: $
Were more than 50% of the Applicant's revenue derived fron one client?
If Yes, specify client and description of services rendered:
Does the Applicant utilize the services of independent contractors or sub-consultants?
If Yes, indicate percentage of billings and whether a certificate of Professional Liability is required of each:
Does the Applicant build, service, repair, install, manufacture or fabricate anything??
Does the Applicant sell any product other than computer software?
If Yes, please describe:
Does the Applicant carry General Liability Insurance?
If Yes, provide:
Insurer:   Limits:
Is a Professional Liability (E&O) insurance currently in force?
If Yes, provide information regarding coverage during the past five (5) years:
Company   Exp. Date   Limits   Premium
During the last five years, have there been any professional liability claims against the Applicant proposed for this insurance?

If Yes, please provide loss runs.
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?
If Yes, please provide details.
Has any insurer cancelled, rescinded, non-renewed or declined any similar insurance for the Applicant proposed for this insurance in the last five years?

If Yes, attach a copy of such insurer's notice.
During the past five years has the Applicant been named as a Defendant or Plaintiff in a lawsuit?
If Yes, please supply full details.
Limits of Liability Desired:
Deductible Desired:
    (You will get a summary page to review before submitting)