Home Office: 82 Hopmeadow Street Simsbury, Connecticut 06070-7683
Executive Risk Indemnity Inc.
APPLICATION FOR MANAGEMENT LIABILITY INSURANCE FOR PROFESSIONAL FIRMS NOTICE: THE POLICY FOR WHICH APPLICATION IS MADE APPLIES, SUBJECT TO ITS TERMS, ONLY TO “CLAIMS” FIRST MADE DURING THE “POLICY PERIOD,” OR ANY APPLICABLE EXTENDED REPORTING PERIOD. THE LIMIT OF LIABILITY AVAILABLE TO PAY DAMAGES OR SETTLEMENTS WILL BE REDUCED, AND MAY BE EXHAUSTED, BY “DEFENSE EXPENSES,” AND “DEFENSE EXPENSES” WILL BE APPLIED AGAINST THE RETENTION. IN NO EVENT WILL THE COMPANY BE LIABLE FOR "DEFENSE COSTS" OR THE AMOUNT OF ANY JUDGMENT OR SETTLEMENT IN EXCESS OF THE APPLICABLE LIMIT OF LIABILITY. READ THE ENTIRE APPLICATION CAREFULLY BEFORE SIGNING. 1.
PLEASE PROVIDE COPIES OF THE FOLLOWING:
Partnership Agreement, Bylaws and Charter; Audited Financial Statements or the equivalent for the most recent fiscal year, including all notes and schedules; Accounts Receivable Aging; Firm Organizational Chart; and Firm Brochures. 2.
GENERAL INFORMATION:
A.
Applicant’s name: Applicant’s address: Applicant’s Website: Nature of operations:
B.
Number of years in business:
List all locations or branch offices. Please use a separate addendum if necessary. City State Years in Operation ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________
C. Current Insurance: 1. a. b. c. d.
D&O (Directors & Officers Liability) Carrier(s) ______________________ Limit ______________________ Premium ______________________ Expiration ______________________
a. b. c. d.
2. EPL (Employment Practices Liability) Carrier(s) _____________________ Limit _____________________ Premium _____________________ Expiration _____________________
3. a. b. c. d.
Professional Liability Carrier(s) ______________________ Limit ______________________ Premium ______________________ Expiration ______________________
a. b. c. d.
4. Fiduciary Liability Carrier(s) _____________________ Limit _____________________ Premium _____________________ Expiration _____________________
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D.
MISSOURI APPLICANTS/AGENTS - DO NOT ANSWER THIS QUESTION. Has a previous insurer that has issued management liability, D & O or employment practices liability coverage to Applicant (either on a stand alone basis or as supplemental coverage provided under some other type of insurance) ever canceled, non-renewed or reduced limits on renewal of such coverage? Yes No If “Yes,” provide details of the circumstances of cancellation or non-renewal on a separate addendum.
E.
Desired coverage:
3.
FIRM COMPOSITION AND MANAGEMENT:
A.
Current number of: Partners (Shareholders): _______ All other professionals: _______
B.
Limit of liability: ________________________
Retention: _________________________
All other full-time employees: _________ Part-time employees (including seasonal and temporary): _________
Please list the committees or boards for which this insurance is sought that are responsible for matters concerning the Applicant’s business operations and finances, and indicate the number of individuals comprising each committee or board. Please use a separate addendum if necessary. Committee/Board
Responsibilities
Number of Members
__________________________ __________________________ __________________________
_____________________________________ _____________________________________ _____________________________________
____________________ ____________________ ____________________
C. Please describe the method and criteria for election or appointment to the committees and boards listed in 3.B. above as well as the length of the term of service on each. Please use a separate addendum if necessary.
D. Have there been any changes in the committees or boards listed in 3.B. above within the past three (3) years for reasons other than death, retirement or term limit? If "Yes," please explain.
E.
Yes
No
Please list the titles of the positions of any individuals serving as administrator, executive or financial officer of the Applicant who are not also practicing professionals of the Applicant and provide a brief description of each office. Title
Description
_________________________________________ _________________________________________ _________________________________________
_____________________________________________ _____________________________________________ _____________________________________________
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F. Stock Ownership: If the Applicant is organized as a corporation, please complete the following table and question F(1) below. If the Applicant is organized other than as a corporation, please proceed to question F(2) below. Classes
Total Number of Shares
Votes Per Share
Percentage Owned by Each Committee/Board Identified in Question 3.B.
A B C
% % %
(1) Does any shareholder own five percent (5%) or more of the voting shares? If so, designate names, percentages of holdings, and any membership in a Committee or Board identified in Question 3.B. “None.”) (If no such shareholders, check here
(2) Does any partner, principal or member own five percent (5%) or more of the equity in the Applicant? If so, designate names, percentages of holdings, and any membership in a Committee or Board identified in Question 3.B. (If no such “None.”) persons, check here
(3) How many shareholders, partners, principals, or members are not responsible for the Applicant’s business operations or finances? 4.
CLAIMS HISTORY:
A.
(1) After inquiry, have any claims or suits been made by or against the Applicant or any Committee or Board listed in item 3.B. above?
Yes
No
Yes
No
If yes, please complete a Supplemental Application - Claims for each such claim or suit. (2) After inquiry, have any claims or suits been made by or against any individual in his or her capacity as a past or present member of any of the Committees or Boards listed in item 3.B. above or any similar committees or boards, or any individual serving the Applicant in any of the positions listed in item 3.E. above, or in any similar administrative or financial position? If yes, please complete a Supplemental Application - Claims for each such claim or suit. B.
(1) After inquiry, please provide a listing of any facts or circumstances which might reasonably be expected to give rise to a claim being made by or against the Applicant or any Committee or Board listed in item 3.B. above. Please use a separate addendum if necessary.
(2) After inquiry, please provide a listing of any facts or circumstances which might reasonably be expected to give rise to claims being made by or against any past or present members of the Committees or Boards listed in item 3.B. above or by or against any individual serving in any of the positions listed in item 3.E. above. Please use a separate addendum if necessary.
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Without prejudice to any other rights and remedies of the Underwriter, any claim arising from any claims, facts, circumstances, or situations required to be disclosed in response to 4.A. or 4.B. above is excluded from the proposed insurance. 5.
APPLICANT’S PRACTICE:
A.
Please provide the following information regarding the Applicant’s five (5) largest practice areas (please use a separate addendum if necessary): Practice Area
_________________ _________________ _________________ _________________ _________________
Description of Professional Services and Representative Clients __________________________ __________________________ __________________________ __________________________ __________________________
Approximate # of Professionals in Area* ____________________ ____________________ ____________________ ____________________ ____________________
Approximate % of Gross Billings Last Fiscal Year _____________________ _____________________ _____________________ _____________________ _____________________
* Need not equal total number of professionals where professionals perform work in a number of areas. B.
How many of the Applicant’s partners, principals, directors, officers or shareholders have left the Applicant in the last five (5) years? ____________ If the Applicant suffered any loss of clients as a result of any such departures, what percentage of Applicant’s billables did such loss represent? _____________
C.
If the Applicant answers “Yes” to any of the following questions, please provide further details on a separate addendum. (1) Has the Applicant closed any branch offices or had any layoffs in the last five (5) years?
Yes
No
(2) Has the Applicant acquired or merged with any other entity in the last five (5) years?
Yes
No
If “Yes” to question 5.C.(2)., did the acquisition include the assumption of liabilities?
Yes
No
Yes
No
(3) Does the Applicant anticipate any branch or office opening or closing, or any merger, consolidations or layoffs within the next twenty-four months? D. What managerial and financial reports are distributed to the partnership and how often are they distributed?
6.
FINANCIAL INFORMATION:
A.
On a separate addendum, please list all loans made by the Applicant to partners, principals or shareholders of the Applicant as well as the original principal amount of the loan, the amount currently outstanding, the maturity date and the purpose of the loan.
B.
On a separate addendum, please list all obligations owed by the Applicant to partners, principals or shareholders of the Applicant, including loans made by partners, principals or shareholders of the Applicant to the Applicant as well as the original principal amount of the loan or obligation, the amount currently outstanding, the maturity date and the purpose of the loan or obligation.
C. On a separate addendum, please describe the Applicant’s process and criteria for determining the compensation of the Applicant’s partners, principals or shareholders. D. Are any of the Applicant’s financial obligations specifically nonrecourse to the partners or shareholders of the Applicant?
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Yes
No
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7.
MATERIAL CHANGE:
If there is any material change in the answers to the questions in this Application before the policy inception date, the Applicant must immediately notify the Company in writing, and any outstanding quotation may be modified or withdrawn. 8.
NOTICE TO APPLICANT:
The Applicant's submission of this Application does not obligate the Company to issue, or the Applicant to purchase, a policy. The Applicant will be advised if the Application for coverage is accepted. The Applicant hereby authorizes the Company to make any inquiry in connection with this Application. 9.
DECLARATIONS, FRAUD WARNINGS AND SIGNATURES:
The undersigned authorized agents of the person(s) and entity(ies) proposed for this insurance declare that to the best of their knowledge and belief, after reasonable inquiry, the statements made in this Application and in any attachments or other documents submitted with this Application are true and complete. The undersigned agree that this Application and such attachments and other documents shall be the basis of the insurance policy should a policy providing the requested coverage be issued; that all such materials shall be deemed to be attached to and shall form a part of any such policy; and that the Company will have relied on all such materials in issuing any such policy. The information requested in this Application is for underwriting purposes only and does not constitute notice to the Company under any policy of a Claim or potential Claim. Notice to Arkansas, Minnesota, New Mexico and Ohio Applicants: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false, fraudulent or deceptive statement is, or may be found to be, guilty of insurance fraud, which is a crime, and may be subject to civil fines and criminal penalties. Notice to Colorado Applicants: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory agencies. Notice to District of Columbia Applicants: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits, if false information materially related to a claim was provided by the applicant. Notice to Florida Applicants: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. Notice to Kentucky Applicants: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. Notice to Louisiana and Rhode Island Applicants: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Notice to Maine, Tennessee, Virginia and Washington Applicants: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. Notice to Alabama and Maryland Applicants: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Notice to New Jersey Applicants: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Notice to Oklahoma Applicants: Any person who, knowingly and with intent to injure, defraud or deceive any employer or employee, insurance company, or self-insured program, files a statement of claim containing any false or misleading information is guilty of a felony.
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Notice to Oregon and Texas Applicants: Any person who makes an intentional misstatement that is material to the risk may be found guilty of insurance fraud by a court of law. Notice to Pennsylvania Applicants: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Notice to Puerto Rico Applicants: Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation with the penalty of a fine of not less than five thousand (5,000) dollars and not more than ten thousand (10,000) dollars, or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances are present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years. Notice to New York Applicants: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to: a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. NOTE: This Application is signed by the undersigned authorized representative of the Applicant on behalf of the Applicant and all of its partners, owners, shareholders, officers, and employees. _______________________________________________________________________ Signature of Applicant's Authorized Representative (Principal, Partner or Shareholder) ___________________________________________________________ Print Name
________________ Date ___________________________ E-Mail Address
REQUIRED INFORMATION: Produced By: Agent:_________________________ Agency: _________________________________ Agency Taxpayer ID or SS No.:
Agent License No.:
Address (Street, City, State, Zip): Submitted By: Agency: Taxpayer ID or SS No.:
Agent License No.:
Address (Street, City, State, Zip):
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