Skip to main content

    Claims, Lawsuits, Complaints and Disciplinary Actions

    1.
    I understand that I must answer “yes” to question 2 and “no” to questions 3–12 to automatically qualify for coverage. If not, additional underwriting review is required.
    2.
    Is the Applicant properly licensed, registered, or authorized in all jurisdictions where the Applicant conducts professional activities for which coverage is sought?
    3.
    Does the Applicant have any knowledge of any fact, situation, allegation, or incident that could reasonably be expected to give rise to a complaint, claim, suit, arbitration, or regulatory inquiry?
    4.
    Has any claim, suit, arbitration, or other legal proceeding alleging a professional error, omission, or wrongful act been made against the Applicant within the past 7 years?
    5.
    Has the Applicant ever been convicted of a felony or is the Applicant currently under criminal investigation, indictment, or proceeding (other than minor traffic violations or DUI)?
    6.
    Has any professional license or registration of the Applicant ever been denied, suspended, revoked, restricted, or non-renewed?
    7.
    Has the Applicant ever been the subject of an investigation, inquiry, or enforcement action by any federal, state, or self-regulatory authority (including insurance, securities, or consumer protection agencies)?
    8.
    Has any complaint been filed against the Applicant with a consumer agency, appointing carrier, broker/dealer, or similar entity?
    9.
    Has the Applicant ever been accused by a professional or trade association of violating a code of ethics or professional conduct?
    10.
    Has any professional liability policy or bond ever been cancelled, non-renewed, declined, issued on special terms, or renewal refused (other than for non-payment where coverage was reinstated)?
    11.
    Has any contract between the Applicant and an insurance carrier, broker/dealer, or similar entity ever been terminated, restricted, or non-renewed for cause?
    12.
    Does the Applicant engage in professional activities outside of standard insurance sales or servicing that may materially increase exposure (e.g., securities activities, specialized commercial lines, or advisory services)?

    Additional Review Required

    Based on your answers, this application does not qualify for automatic approval. A member of our underwriting team will need to review your responses.

    You may call us at 800-XXX-XXXX or submit a request through our contact form.

    Contact Us

    Electronic Signature

    I confirm that all information provided in this application is true, complete, and accurate to the best of my knowledge. I understand that this information will be relied upon in the underwriting and issuance of my professional liability (Errors & Omissions) insurance policy.

    I further confirm that I am authorized to submit this application on behalf of the applicant, and that any material misrepresentation or omission may result in denial of coverage, rescission of the policy, or denial of a claim.

    This name will be pulled from the insured contact information.