Property Managers'
Errors & Omissions and
Commercial Crime
Application

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NOTICE

WITH RESPECT TO ALL COVERAGE PARTS, THE POLICY YOU ARE APPLYING FOR IS A CLAIMS-MADE POLICY, AND SUBJECT TO ITS PROVISIONS, APPLIES ONLY TO ANY CLAIM FIRST MADE DURING THE POLICY PERIOD. NO COVERAGE EXISTS FOR CLAIMS FIRST MADE AFTER THE END OF THE POLICY PERIOD UNLESS, AND TO THE EXTENT, THE EXTENDED REPORTING PERIOD APPLIES.

DEFENSE COSTS, AS WELL AS ANY LOSSES AS DEFINED IN EACH APPLICABLE COVERAGE PART, REDUCE THE LIMIT OF LIABILITY AND ARE SUBJECT TO THE RETENTION. PLEASE REVIEW THE POLICY CAREFULLY AND DISCUSS THE COVERAGE WITH YOUR INSURANCE AGENT OR BROKER.

Agent/Broker Information
Contact Name:
Firm Name:
Address 1:
Address 2:
City:
State:
Zip:
Phone:
e.g.(123)456-7890
Fax:
e.g.(123)456-7890
Email:
How did you hear about us?
I.General Information
1.
a. The Applicant to be named in Item 1 of the Declarations (the Named Insured):
 
b. Street Address:
 
City:
State:
Zip:
 
Telephone: e.g.(123)456-7890 Fax: e.g.(123)456-7890
 
Website Address: 
2.
Proposed effective date of coverage being applied for: (mm/dd/yyyy)
3.
Limit Requested: Deductible requested: 
4. Officer designated to receive correspondence and notices from the Insurer.
 
Name:  Direct Phone: 
 
Title:   E-mail:  
5.
Years in Business: 
6.
Does the Principal of the firm hold a real estate broker's license?
7.
Number of Employees: 
 
a. Number of employees on Client Premises (Coverage A1. only):
8.
Nature of services provided by the applicant:  
9. Subcontracted work:
 
a. Does the Applicant subcontract any professional services to fulfill contracts or engagements for clients?
 
b. What percentage of current projected gross revenues is attributable to subcontracted work?
10.
Does the Applicant use a written contract or agreement with all clients?
 
a. Does an attorney review such contracts or agreements prior to use?
 
b. Does the standard contract or agreement contain a limitation of liability clause in favor of the applicant?
 
If "no" to questions 10, 10a or 10b, please provide details:(max 1000 characters)
11. During the last 18 months or over the next 12 months does the applicant expect to be in any of the following:
 
a. Merger, consolidation, acquisition, tender offer or divestment of stock?
 
b. Layoffs, staff reduction or facility closing?
 
c. Material changes in nature of operations?
 
d. Senior management changes?
 
If "yes" to questions 11a, 11b, 11c or 11d please provide details: