Claim Professionals Liability Insurance Company, A Risk Retention Group

Application for Claims Made and Reported Errors and Omissions and General Liability Policy

Important – Coverage provided by CPLIC may vary significantly from coverage with similar names provided by other companies. Please review the coverage, terms, conditions and exclusions carefully to ensure that you are obtaining the correct type and amount of coverage for your business.

This policy is issued by your risk retention group. Your risk retention group may not be subject to all of the insurance laws and regulations of your state. State insurance insolvency guaranty funds are not available for your risk retention group.

Section One – Named Insured

Named Insured:_________________________________________________________________________________
Company organization is a: ž Corporation ž Partnership ž LLC ž Sole Proprietorship or ž Other (Please specify): ________________________________________________________________________________
Date Company Established: ______________ 4. Date Company Came Under Current Ownership ______________

5. Primary Individual for Contact: (Please print) __________________________________________

6 Named Insured Address: _________________________________________________________________________

____________________________________________ ______ ____________________

E-mail: _____________________________ Phone: (____) _____-____________ Fax (____) _____-___________

Primary Operating Business Name: _________________________________________________________________
Primary Operating Address (Considered Location One): _____________________________________________________

____________________________________________ ______ ___________________

Telephone: (____) _____-____________ Fax (____) _____-___________

If coverage is desired for other operating names, entities or branch offices, list them below. If a name or entity is not listed on the application, there will be no coverage provided by the CPLIC policy in the event of a claim. Attach additional pages if necessary.

	Location Two
Name
DBA or Assumed Business Name
Address
City, ST Zip
Telephone
Fax
Date Established/Purchased
Relationship to Named Insured
Services Claims In These States

	Location Three
Name
DBA or Assumed Business Name
Address
City, ST Zip
Telephone
Fax
Date Established/Purchased
Relationship to Named Insured
Services Claims In These States

Section Two – Coverages

First Effective Date of CPLIC Coverage Applied For: ____/_____/_________
Limit of Liability Applied For: ________________________________________Deductible_________________
Prior E&O & GL Coverage – Current E&O Insurance Company: ______________________________________

Policy Number: __________________________________________________

Effective and Expiration Dates: _____________________________________

Limit of Liability: ___________________ Deductible __________ Premium __________

Current General Liability Company

Policy Number: __________________________________________________

Effective and Expiration Dates: _____________________________________

Limit of Liability: ___________________ Deductible __________ Premium __________

Retroactive Date: If you wish to purchase Retroactive Date coverage to potentially provide coverage under the CPLIC policy for acts, errors, omissions or occurrences which occurred prior to the first date of coverage of the CPLIC policy, specify the Retroactive Date applied for and attach a copy of your most recent declarations page for your existing coverage.: _________/__________/___________

Section Three – Professional Services

For each state in which you provide claims related services, describe in detail the services provided by each location for which you are applying for insurance: _____________________________________________________________

_____________________________________________________________________________________________

Please attach additional pages if necessary to fully describe your operations. Also, please attach copies of brochures and marketing / promotional materials that are or can be made available to clients or potential clients.

For the professional claims services described above, please indicate gross revenue by state for the 12 months prior to the proposed effective date of coverage: $_________________________________________________________
Do you anticipate any material changes in the professional claims services described above for the 12 months following the proposed effective date of coverage? žNo žYes If ‘Yes”, please describe by state in detail the expected changes: ______________________________________________________________________________________

_____________________________________________________________________________________________

For the 12 months following the proposed effective date of coverage, including the impact of changes described above, indicate your anticipated gross revenue by state: $_______________________________________________
Personnel Count: Employee claims professionals for all locations: __________________

Non-Employee claim professionals all locations: __________________

Administrative or Clerical staff all locations: __________________

Executive staff all locations __________________

Total of all individuals: __________________

Professional Organizations and Designations to which the Named Insured and it’s personnel belong or have membership in: ________________________________________________________________________________
If you have listed a number for Non-Employee claims professionals above, describe your management and supervision policies specifically for quality assurance of work performed by Non-Employee personnel and the approximate percentage of gross revenue attributed in whole or in part to Non-Employee or Independent Contractor personnel: $___________________________________________________________________________________

_____________________________________________________________________________________________

Do you retain or cause to be retained other individuals or companies for expert or investigative services for or on behalf of client companies? žNo žYes If ‘Yes’, please describe in detail your procedures for retaining outside services, monitoring quality assurance of their work, payment approval procedures for outside services and disclosure of outside service individual or firm professional and general liability insurance coverage: _____________________________________________________________________________________________

_____________________________________________________________________________________________

Please list the five largest clients of the Named Insured and the associated detail below:

Client Name Services Provided Contract (Y or N) Gross Annual Revenue

1._________________________ ____________________________ ___________ _____________________

2.._________________________ ____________________________ ___________ _____________________

3.._________________________ ____________________________ ___________ _____________________

4.._________________________ ____________________________ ___________ _____________________

5.._________________________ ____________________________ ___________ _____________________

Total Annual Revenue for 5 Largest Clients: $

Please indicate the percentage of gross income for your organization by:

Insurance Companies	%
Self-Insured Organizations	%
Governmental Entities	%
Other	%
Total	100 %

Please indicate the percentage of gross income for your organization by:

Non-Contract Claims	%
Contract Claims Administration	%
Appraisal	%
Other	%
Total	100 %

Do the Named Insured or any personnel provide professional services other than claims services, including but not limited to agency or brokerage services? žNo žYes, If ‘Yes’, please describe in detail below: _____________________________________________________________________________________________

_____________________________________________________________________________________________

CPLIC does NOT provide coverage for professional services other than claims services or agency/brokerage services necessary to support the Named Insured’s professional claims service operations and clients.

Do the Named Insured or any of its described operating locations provide professional claims services under contract? žNo žYes, If ‘Yes’, please describe in detail below: ___________________________________________

_____________________________________________________________________________________________

CPLIC has the right to inspect for the purposes of underwriting all contracts for services.

Do the Named Insured or any of its described operating locations provide services which necessitate financial management, bank account access or check issuance for any client companies? žNo žYes, If ‘Yes’, please describe in detail by state and location below: ________________________________________________________________

_____________________________________________________________________________________________

If ‘Yes’, please list your Financial / Fiduciary Bond Insurance Company ____________________________________

Policy Number: _____________________Eff/ Exp Dates: _________________Limit of Liability: ________________

28. Business mix – Please indicate the percentage of total revenue of the Named Insured for each:

Workers’ Compensation	%
Property	%
Liability (Auto, GL, HO, etc)	%
Professional Liability	%
Life, Health and Accident	%
Catastrophe Claims	%
Auto or Heavy Equipment Appraisal	%
Total	100%

Do the Named Insured or any of its described operating locations provide services in states other than the state in which the office is physically located? žNo žYes, If ‘Yes’, please describe in detail by state and location below:

_____________________________________________________________________________________________

Are all employee, non-employee and management individuals licensed by the state(s) in which they provide claims services? žYes, žNo If ‘No’, please describe in detail below (exclude clerical, support and non-claim professionals):

_____________________________________________________________________________________________

Please describe the manual and computer processing systems and applications used in the Named Insured’s operations and processes and procedures to ensure compliance with client, state and federal record retention requirements, backup and business continuity disaster plans in place and other automated processing considerations which impact upon the Named Insured’s professional claims services (attach copies of written plans, system and software specifications if available). Please differentiate by type of claim and internal processing systems from processing done on systems off-site, including those owned/operated by client organizations: _____________________________________________________________________________________________

_____________________________________________________________________________________________

_______________________________________________________________________________ ______________

Section Four – Prior Activities and Claims History

For the period of five (5) years prior to the proposed effective date of CPLIC coverage:

Has the Named Insured or any of its operating locations, including businesses acquired:

a) Had any company or personnel license denied, suspended or revoked? žNo žYes, If ‘Yes’, please describe in detail below and attach explanatory documentation: ____________________________________________________

_____________________________________________________________________________________________

b) Been investigated, disciplined, sued or fined by any regulatory agency? žNo žYes, If ‘Yes’, please describe in detail below and attach explanatory documentation: ____________________________________________________

_____________________________________________________________________________________________

Has the Named Insured or any of its operating locations, including business acquired, had a policy or application for Professional or General Liability non-renewed, declined, cancelled, rescinded or refused? žNo žYes, If ‘Yes’, please describe in detail below and attach explanatory documentation: __________________________________________

_____________________________________________________________________________________________

Has the Named Insured or any of its operating locations, including businesses acquired and all employee and non-employee personnel, had any claims, lawsuits or other actions made against them? žNo žYes, If ‘Yes’, please describe in detail below and attach explanatory documentation: __________________________________________

_____________________________________________________________________________________________

Is the Named Insured or any of its employee or non-employee personnel aware of any actual or alleged facts, circumstances, situation, action, error or omission which may be reasonably expected to result in a claim, lawsuit or other action to be taken against the Named Insured, any of its operating locations or employee or non-employee personnel? žNo žYes, If ‘Yes’, please describe in detail below and attach explanatory documentation: ___________

_____________________________________________________________________________________________

Premium Donation to Claims Organizations

If this application is accepted, the Named Insured can specify up to 3% of the annual earned premium to be donated to insurance, self-insurance or claims related organizations, subject to the approval of CPLIC. Specify your selections if you choose to redirect a portion of your premium to go to such organizations:

Organization	Percentage of Premium
	%
	%
	%
Total Premium Donation Redirect	3%

The CPLIC policy to which this application relates may not provide coverage for prior acts that you or any employee or non-employee personnel of the Named Insured or any of the Named Insured’s operating locations have knowledge of on or prior to the date of this application.

Read the following closely, date and sign the application.

I, the undersigned, being fully authorized and permitted by the Named Insured to execute this application for coverage, understand that the coverage applied for applies only on a Claims Made basis and only for claims which are first made against the Named Insured and reported to CPLIC during the policy period. I understand that coverage ceases upon termination of the policy, subject to modification by availability and payment of premium for extended reporting period coverage.

By signing this application for coverage, I, on behalf of the Named Insured and all of its operating locations, subsidiaries, and employee and non-employee personnel, represent that this application and all attachments, amendments and documentation are complete, accurate, representative of the full scope and depth of my knowledge and that the representations made herein are made with my full knowledge and consent that I have conducted sufficient internal investigation to have a reasonable belief that all answers and representations are full, complete and accurate. I agree that, after completion of this application, I will send written notice of any changes, modifications or other material instances which occur or come to my attention prior to the issuance of the CPLIC policy should the application be accepted by CPLIC. CPLIC reserves the right to modify or withdraw from any offers of coverage based upon information provided by the Named Insured or discovered through any other source in its underwriting review of this application or any time thereafter.

Coverage provided by CPLIC is conditioned upon underwriting review and acceptability of the Named Insured as a member of Claim Professionals Liability Insurance Company, Risk Retention Group, and is subject to the RRG membership and capital requirements.

____________________________________________ Name of Applicant (Print) _________________________________

Signature of Applicant

_________________________________

Date Application Completed