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:*
- Sole Proprietor
- Corporation
- Partnership
- Joint Venture
- Other
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*
DD slash MM slash YYYY
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Name:	Years in Position:	Years Experience:	Qualifications:

Breakdown of Total revenue by Activity	(%)

Details	Revenue ($)

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

General Information

Company Details

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

Operations Of Company

Contracts

Insurer History & Requirements

Claims History

Claims History (Continued):