RENEWAL APPLICATION - Errors & Omissions/Professional Liability Insurance

THIS APPLICATION SHALL FORM PART OF ANY ERRORS & OMISSIONS OR PROFESSIONAL LIABILITY POLICY WHICH MAY BE ISSUED BY  PRO-FORM INSURANCE SERVICES (B.C.) INC. TO THE PROPOSED APPLICANT.

1.	THE APPLICANT
Name of Applicant:	If different from above, state name under which business/practice is conducted:	
Street Address of main office:	Please indicate:
Corporation	Partnership	Individual	
City	Province	Postal Code	Locations of Branch Offices	
Does the proposed Insured Organization have a Website?
Yes	No	If “Yes”, please provide the Web address	

2.	OPERATIONS
A.	Has there been any change in the description of your services provided on your last Application form?	Yes	No

If “Yes”, please provide a full description of operations; (please attach brochures and promotional literature):

B.	Since the completion of the last Application form, have there been any changes in the control or ownership of the organization, the association with any other firm, corporation, company or individual?
If “Yes”, please provide full details

C.	Please indicate your gross annual fees or income:
For the past year:	$	and anticipated for next year:	$
D.	Please provide a breakdown of your annual Gross Revenue by the type of service provided:

Yes	No

E.	Do you use independent contractors?	Yes	No

If “Yes”, what percentage of your ongoing operations are worked on by independent contractors?	%

F.	What proportion of your revenue is derived from clients outside of Canada?

Country	% of, revenue	

		

G.	What proportion of your revenue is derived from services provided outside of Canada?

Country	% of revenue	

		

H.	Do you anticipate any changes in the sources of your revenue or nature of your operations in the next 12 months?
If “Yes” please provide details:

Yes	No

I.	In general, who are your clients?

Please complete schedule A, listing your firm’s 3 largest projects in the last 12 months.
J.	During the last year, have you changed your professional services contract or procedure for using contracts?
If “Yes”, please provide details and a copy of the new contract.

Yes	No

3.   PROFESSIONAL BACKGROUND

A.	During the past year did the Applicant or any of its employees obtain any association memberships?
If “Yes”, please provide details:

Yes	No

B.	During the past year has the Applicant or any of its employees ever been investigated by, or suspended from practice by, any body governing the practice of this profession or any other body e.g. a court? If “Yes”, please provide details:

Yes	No

C.	During the past year were there any changes in legislation which governs the practice of the Applicant?
If “Yes”, please attach relevant extracts.

Yes	No

D.	During the past year has there been any change in your principals, partners or senior staff members?	Yes	No
If “Yes” please provide the following information and attach a resume for each

Full Name	Duties/Titles	Education	Years exp.	

				
				
E.	Please indicate the total number of employees:
Professional:	Sales Representative:	Clerical:	Other:
F.	Please indicate the total number of partners, principals and employees who also act in the capacity of manager(s):

4.	

LOSS HISTORY		
	In the past five (5) years, have the Applicant, partner, principals or employees had any claims because of professional services, or are the Applicant, partners, principals or employees aware of any facts or circumstances or allegations which may give rise to a claim? If “Yes”, please attach details:	

Yes	

No	

It is agreed that if such facts or circumstances exist, whether or not disclosed, any claim arising from or related to such facts or circumstances may be excluded from this proposed coverage.	

5.	

REQUESTED COVERAGE				
	A.	Limit of Liability Per Occurrence:	$	Aggregate:   $			
	B.	Deductible	$			

6.    DECLARATIONS AND SIGNATURE
The undersigned declares that he/she is duly authorized by the proposed Insureds to complete and sign this application on their behalf and that the statements set forth herein are true and complete.
The undersigned agrees that:
(i)	the signing of this application does not bind the undersigned, the proposed Insureds or Pro-Form Insurance Services (B.C.) Inc. to effect insurance;
(ii)	this application, all prior applications for this coverage and all additional information provided herewith shall be the basis of the contract, should a policy be issued, and shall be deemed to be attached to and shall form part of the policy;
(iii)	if there is any change to the information supplied on this application between the date of this application and the effective date of the policy, notification will be sent in writing to Pro-Form Insurance Services (B.C.) Inc., and any outstanding quotation may be modified or withdrawn; and
(iv)	Pro-Form Insurance Services (B.C.) Inc. is hereby authorized to make any investigation and inquiry in connection with this application that it deems necessary.
ANY PERSON, WHO KNOWINGLY OR WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON, FILES AN APPLICATION FOR INSURANCE CONTAINING FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING THE INSURER, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUD, WHICH IS A CRIME.
Date:                                                                                                                                          * Signed:

Corporation:	Name & Title (please print):
*Please Note: The application must be signed by a Principal, Partner or Executive Officer
A POLICY CANNOT BE ISSUED UNLESS THIS APPLICATION IS PROPERLY SIGNED AND DATED

Schedule A
Question # 2.I - add further pages if needed

Name of Client:

Date of Project:	Total Fees Received:

Services Rendered:

Name of Client:

Date of Project:	Total Fees Received:

Services Rendered:

Name of Client:

Date of Project:	Total Fees Received:

Services Rendered: