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Professional Liability or Errors and Omissions ( E&O ) Insurancelaxmikant2020-08-28T11:56:41+00:00

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

  • General Information

  • Company Details

  • Name:Years in Position:Years Experience:Qualifications: 
  • Professional:Clerical:Other:
  • 7. Fees from Applicant’s Operations (in CDN Dollars):

  • Operations Of Company

  • Breakdown of Total revenue by Activity(%) 
  • DetailsRevenue ($) 
  • Contracts

  • (in %)
  • Insurer History & Requirements

  • Effective DateRetro DateLimitDeductibleCurrent PremiumInsure
  • Effective DateRetro DateLimitDeductibleTarget PremiumInsure
  • Effective DateLimitDeductibleTarget PremiumInsure
  • 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?

  • 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.
  • 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.
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