Miscellaneous Professional Liability
Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.
Provide a list of all claims, suits or other demands for wages, reinstatement or other relief against the Applicant in the past five years?
Please note the professional service that best describes the primary business for which Insurance is being sought?
If Yes, please answer the following question:
Gross Annual Revenues for all entities to be covered
(Start-ups please provide best estimate of current fiscal year. $0 or $1 is not an acceptable value)
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binding agreement to your policy or coverages. Changes and
payments to policies are not effective or binding until you, or any
party involved, receive official notice from either your insurance agent,
or your insurance company. If you have any questions, please feel free to
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