Monarch Insurance Brokers

MISCELLANEOUS PROFESSIONAL LIABILITY APPLICATION

NOTE: Completion of this application form does not bind the Insurer to offer the insurance nor does it obligate the Applicant to purchase the insurance. This application is a declaration and shall form part of any policy wich may be issued.

Do not print this page! For blank forms click here. To submit it online, complete this page and select the "Finish" button at the bottom of the page

NOTE: If the spaced provided to answer any of the questions on this application are insufficient to fully answer the question, please use the remarks section at the end of the form. If it is a continuation from a particular question, please be sure to indicate which question.

APPLICANT:

1. Name of applicant

Address

City

Province

Postal Code

Email

Phone Number

Fax Number

Website

2. Applicant is:
Individual
Partnership
Corporation
Other

3. Year established

SEND COPY OF APPLICANT'S LETTERHEAD 4. Limits of Liability Desired:
$ (each Claim/Annual Aggregate)
5. Deductible Desired:
$2,500
$5,000
$10,000
$25,000
Other

6. Please describe in detail the professional services for which coverage is desired:

7. Please list provide the following information for all partners, principals, employed professionals and key employees (please send separate page if necessary).

Name	Address	SIN#	D/O/B

8. Is the Applicant engaged in any business or profession other than that described in Q.6? If YES, please send an application and estimated revenues.
Yes
No

9.(A) Please indicate the total annual gross revenues derived from the services described in Question 6 for the past three years and the projected revenues for the current year.

YEAR	REVENUE
Current

9.(B) Split of Revenue
(1) Canada %
(2) U.S.A. %
(3) Other %

10. Please indicate the total annual gross revenues derived from the services described in Question 6 for the past three years and the projected revenues for the current year.

SERVICE	PERCENT OF REVENUE

11. Is the Applicant controlled or owned by or associated or affiliated with, or does it own, any other firm or business enterprise? If YES, please send an explaination and indicate if any services described in Question 6 are provided to such firm or business enterprise.
Yes
No

12. During the past three years, has the Applicant's name been changed, or has the Applicant purchased, merged, or consolidated with any other business or has the Applicant been purchased? If YES, please send an explanation to Monarch.
Yes
No

13. Are any changes in the nature or size of the Applicant's business anticipated over the next 12 months? If YES, please send an explaination to Monarch. Changes in size less than 25% need not be explained.
Yes
No

14. Please indicate the number of:
a) Principals, partners, officers and professional employees directly engaged in providing services to clients.
b) All other (non-professional/clerical)

15. Please provide the following:

Names of all Partners, Principals, and Key Employees	Professional Qualifications/Designations	# Of Years in Practice	# Of Years with Applicant

16. Please list professional associations to which the Applicant belongs:

17. Has the Applicant provided services to any governmental entities? If YES, please send an explanation to Monarch.
Yes
No

18. Has the Applicant provided services to any employee benefits plans, including any pension plans or does it plan to do so? If YES, please send an explanation to Monarch.
Yes
No

19. Has the Applicant provided services to any bank, savings and loan or other financial institution, or does it plan to do so? If YES, please send an explanation to Monarch.
Yes
No

20. Please indicate the Applicant's five largest jobs/projects during the past three years, showing client's name, services provided and gross revenues for each:

21. Does any director, officer, employee or partner of the Applicant serve on the board of directors of any client of the Applicant? If YES, please send an explanation to Monarch.
Yes
No

22. Does the Applicant use a written contract with clients?
In all cases
Sometimes
No

23. Does the Applicant subcontract work to others?
Yes
No

24. Does the Applicant have a written procedural manual for employees to follow?
Yes
No

25. Does the Applicant have a formalized training program for newly hired employees?
Yes
No

26. Does the Applicant have promotional literature? If YES, please send sample copies of all types to Monarch.
Yes
No

27. Has any errors and omissions or professional liability insurance ever been declined or cancelled? If YES, please send an explanation to Monarch.
Yes
No

28. Is any errors and omissions or professional liability insurance currently in force?
Yes
No

Company	Expiration Date	Limits	Premium

RETROACTIVE DATE OF CURRENT POLICY:

29. Does any director, officer, employee or partner of the Applicant have knowledge or information of any act, error or omission which might reasonably be expected to give rise to a claim? If YES, please send an explanation to Monarch.
Yes
No

30. Has the Applicant or any director, officer, employee or partner of the Applicant ever been the subject of disciplinary action as a result of professional activies? If YES, please send an explanation to Monarch.
Yes
No

31. Please send a list and status of all errors and omissions claims made during the past three years against the Applicant or any director, officer, employee or partner of the Applicant. If none please check the box.
None

SUPPLEMENTAL CLAIM INFORMATION FORM

APPLICANT'S INSTRUCTIONS: This form is to be completed by Applicant who has been involved in any claim or suit or is aware of any facts, circumstances, acts, errors or omissions which may give rise to a professional liability claim. COMPLETE ONE FORM FOR EACH CLAIM OR CIRCUMSTANCE.

If space is insufficient to answer any question fully, please send information on separate sheet. Answer all question completely.

NOTE: If more than one claim form is required, please visit the Monarch website and use the blank/printable form for more copies.

1. Full name of Applicant:

2. Full name individual(s) or firm involved in claim:

3. Full name of Claimant:

4. Indicate whether:
Claim/Suit or
Incident

5. Date of alleged error:

6. Date of claim:

7. a) Description of claim (Provide enough information to allow evaluation and use a separate exhibit if additional space is required and include a copy of the complaint):

b) Description of case and events:

8. Additional defendants:

9. IF CLOSED:
Total loss Paid including Deductibles:

Indicate whether:
Court judgment or
Out-of-court settlement

10. IF PENDING:
Claimant's settlement demand $
Defendant's offer for settlement $
Insurer's loss reserve $
Deductible $

Is claim in Suit? If YES, Amount asked in complaint:
Yes
No
$

11. Name of insurer :

REMARKS (optional - or use to complete questions above)