Professional Liability or Errors and Omissions ( E&O ) Insurance

General Information

Name of Applicant(s) (include all subsidiaries):*

Address*

Street Address City ZIP / Postal Code

Telephone:*

Email*

Website

Company Details

1. Date Company was Established (MM/YY):*

2. Company Structure:*

3. Number of Directors, Officers or Partners (please attach resumes):*

4. Details of Directors, Officers or Partners:*

Name:	Years in Position:	Years Experience:	Qualifications:

5. Number of Employees:*

Professional:	Clerical:	Other:

6. Are ALL Employees Covered by WCB?*

Yes
No

7. Fees from Applicant’s Operations (in CDN Dollars):

Canadian Revenue (Last Completed Year)*

Canadian Revenue (Estimate For Current Year)*

Canadian Revenue (Estimate For Next Year)*

USA Revenue (Last Completed Year)*

USA Revenue (Estimate For Current Year)*

USA Revenue (Estimate For Next Year)*

Foreign Revenue (Last Completed Year)*

Foreign Revenue (Estimate For Current Year)*

Foreign Revenue (Estimate For Next Year)*

Profit/Loss (Last Completed Year)*

Profit/Loss (Estimate For Current Year)*

Profit/Loss (Estimate For Next Year)*

8. Date of Company Financial Year End (DD/MM):*

9. Annual Payroll:*

Operations Of Company

10. Description of Operations:

11. Breakdown of Total revenue by Activity (% must equal 100%):

Breakdown of Total revenue by Activity	(%)

12. Are you involved in any manufacture, construction, alteration, repair, installation, sale, supply of products, other than in a pure consultancy capacity as described above?*

Yes
No

if yes, please provide full details:*

13. Does the applicant perform any activities or provide any services outside of Canada?*

Yes
No

a. if yes, please provide complete details including the services provided and revenue:*

Details	Revenue ($)

14. Are any material changes to activities anticipated in the coming year?*

Yes
No

if yes, please provide full details:*

15. Does the applicant perform any hands-on work (if yes, please provide details below)*

Yes
No

if yes, please provide full details:*

16. What professional associations does the applicant belong to?*

17. is there any legislation in force which govern the applicants operations*

18. Does the applicant engage in any business or professional activities other than described above?*

Yes
No

19. Has the applicant ever been investigated or suspended from practice by any governing body of your profession*

Yes
No

20. is the applicant controlled, owned or associated with any other company, firm or corporation?*

Yes
No

Contracts

21. Does the applicant always use standard forms of contract, agreement or letter of appointment?(please attach)*

Yes
No

22. What percentage of work is subcontracted to a third-party?*

(in %)

23. if work is subcontracted, are written contracts used for all sub-contractors/sub-consultants?*

Yes
No

24. Do your contracts with sub-contractors always contain indemnification and hold harmless provisions?*

Yes
No

25. Does the applicant always ensure that sub-contractors maintain adequate professional indemnity insurance?*

Yes
No

Insurer History & Requirements

Please provide details of your current Errors & Omissions insurance policy:*

Effective Date	Retro Date	Limit	Deductible	Current Premium	Insure

Please provide details for your required Errors & Omissions insurance policy:*

Effective Date	Retro Date	Limit	Deductible	Target Premium	Insure

Please provide details for your required Commercial general Liabilty insurance policy:*

Effective Date	Limit	Deductible	Target Premium	Insure

Claims History

regarding all of the types of insurance to which this application form relates, AFTER ENQUIRY:
a) Are you aware of any loss or damage, whether insured or not, that has occurred to any of the Companies to be insured (or to any existing or previous business of the partners or directors of any of the Companies to be insured) within the last 5 (five) years, or
b) Are you aware of any circumstances which may give rise to a claim against any of the Companies to be insured or any partners or directors thereof, or
c) Have any claims or cease and desist orders been made against any of the Companies to be insured, or partners or directors thereof, or
d) Have any partners or directors of the Companies to be insured been found guilty of any criminal, dishonest or fraudulent activity or been investigated by any regulatory body?

With reference to questions a, b, c and d above:*

Yes
No

Claims History (Continued):

if the answer to the above is ‘Yes’, then please attach full details including an explanation of the background of events, the maximum amount involved/claimed, the status of the claim(s) or circumstance(s) and any reserve(s) or payment(s) made by you and/or by insurers, and the dates of all developments and payments.

Additional Notes:*

Declaration

I agree to the privacy policy.

i / we declare that after proper enquiry the statements and particulars given above are true and that i /we have not mis- stated or suppressed any material fact.

i / we agree that this Application Form, together with any other material information supplied by me / us shall form the basis of any contract of insurance effected thereon.

i / we undertake to inform underwriters of any material alteration to these facts occurring before the completion of the contract.

Name*

Date*

CAPTCHA