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    Claims, Lawsuits, Complaints and Disciplinary Actions

    1.
    I understand that I must answer “yes” to question 2 and “no” to questions 3–14 to automatically qualify for coverage. If not, additional underwriting review is required.
    2.
    Does Applicant have a valid license / registration in all jurisdictions in which Applicant will act as an Agent, and as a Registered Representative if applicable?
    3.
    Has any complaint, claim, suit or arbitration for alleged malpractice, error, omission, mistake or other wrongful acts ever been made against Applicant in the last 10 years?
    4.
    If Applicant is or was a “registered representative,” are there or were there any “yes” answers on Applicant’s U4, or have any complaints been expunged in the past? (If Applicant was never a “registered representative,” answer no.)
    5.
    After a review of Applicant’s records, does Applicant have any knowledge or information of any fact, situation, allegation or incident which may result in a complaint, claim, suit or arbitration against Applicant?
    6.
    Is Applicant aware of or involved in any fee or other type of dispute with a client?
    7.
    Has any professional license or registration of Applicant ever been denied, suspended, revoked, non-renewed or restricted in any way?
    8.
    Has Applicant ever been the subject of any investigation, inquiry or complaint by any state or federal regulatory agency, or any other agency (including, but not limited to, the SEC, NASD, FINRA, state securities, corporation or insurance department) that resulted in a regulatory enforcement or consent order, cease and desist order or other enforcement order, disciplinary action, sanction, censure, reprimand, fine, suspension or formal reprimand by any court, or is Applicant currently under investigation by any of these authorities?
    9.
    Has any complaint ever been filed against Applicant with a consumer agency, Applicant’s broker/dealer or an appointing insurance carrier, or is Applicant currently under investigation by any of these authorities?
    10.
    Has Applicant ever been accused by a professional association of violating that association’s code of ethics?
    11.
    Has Applicant ever been convicted of any felony, or of any business-related misdemeanor, or is Applicant currently under investigation or indictment, or otherwise named as a defendant, respondent, or party to any criminal proceeding other than minor traffic violations?
    12.
    Has any contract between Applicant and his/her insurance company, broker/dealer or others ever been suspended, restricted, terminated or non-renewed for cause?
    13.
    Has Applicant ever had his/her professional liability insurance policy or fidelity bond declined, canceled, issued on special terms, renewal refused, or had a request that his/her application for insurance or for a bond be withdrawn?
    14.
    Within the last 10 years has Applicant, or any professional business or entity of which Applicant is or was a principal or owner, declared bankruptcy?

    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.