Errors and Omissions Quote Form

Contact Information
Name of Business:
Contact Name:
Address:
City:
State:	Zip:
Business Phone:	Fax:
Best Time To Call:	AM PM
E-mail Address:

Business Information
Business Status:	Other:
Date your firm was established:
Where is your firm licensed or registered?
Provide the number of your:
Partners or officers:
Technical personnel:
Clerical personnel:
List the qualifications of key personnel:

List professional societies and trade associations relating to the services to be insured in which you or any of your officers are a member:

Is coverage desired for any subsidiary(ies), affiliates, branch offices or other related entities? Yes No
If Yes, provide the following information for each by attachment: Name, city, state, date established and the relationship to you including percentage of ownership, if applicable.

Additional Questions
All remaining questions on this application apply to the persons or entities listed in questions above.
In the past five years has the name of your company been charged and/or has your business been reorganized or restructured? Yes No
If Yes, provide details:

Within the past five years, have you acquired any business, or have you merged or consolidated with any entity? Yes No
If Yes, provide the following information:
Name of Entity:
Date of Transaction:
Type of Transaction:
In any of the transactions listed above, did you assume the liabilities (i.e. responsibility for prior acts) of the acquired, merged or consolidated entity? Yes No
If Yes, provide details of the liability(ies) assumed.

Operations

Briefly describe the nature of your business (i.e. types of services performed).

Briefly describe your five largest jobs or projects during the past five years including the type of service performed and the revenues generated from each.

For what types of claims or exposures are you requesting coverage?

What safeguards or procedures do you employ to avoid those claims or reduce those exposures?

Do you use a written contract or agreement describing the services you will provide? Yes No

If No, explain how you reach agreement with your client regarding the services to be rendered.

Do you ever assume liability for others in your contracts?
Yes No

If Yes, explain those circumstances.

Do all contracts contain a hold harmless or indemnity agreement insuring to your benefit? Yes No

If No, explain those circumstances.

Do any of your contracts contain guarantees or warranties?
Yes No

If Yes, explain the nature of the guarantee or warranty:

Have your contracts and procedures been reviewed by a law firm experienced in your field? Yes No

If no, explain why they have not:

Provide the following information regarding your income:

Domestic Operations:

Gross billings, sales, fees commissions
(pick one basis)

Past 12 Months	Current 12 Months	Est. for Coming Year

Foreign Operations:

Gross billings, sales, fees commissions
(pick one basis)

Past 12 Months	Current 12 Months	Est. for Coming Year

Is your income contingent upon generating savings or earnings for your clients?
Yes No

If Yes, describe the nature of those contingencies in detail:

Claim Experience

Have any claims, suits or proceedings been made during the past five years against any of you or any of your predecessors in business, subsidiaries or affiliates or against any of their past or present partners, owners, officers, sales persons or employees?
Yes No

If Yes, please give details of each.

The policy for which you are applying, if issued, will not insure any claims, suits or proceedings made against any of you before the inception date of the policy or any subsequent claims, suits or proceedings arising therefrom.

Are any of you aware of any actual or alleged fact, circumstance, situation, error or omission which may reasonably be expected to result in a claim being made against you or any of the persons or entities described the previous question?
Yes No

If Yes, explain:

The policy for which you are applying, if issued, will not insure any claims that can reasonably be expected to arise from any actual or alleged fact, circumstance, situation, error or omission known to any of you before the inception date of the policy.

Have any of you or any of your predecessors in business, subsidiaries or affiliates or any of their past or present partners, owners, officers, safes persons or employees been investigated and/or cited by any regulatory agency for violations arising out of your or their activities?
Yes No

If Yes, please give details.

Prior or Current Coverage
Provide the following information for similar insurance, if any, carried during the last five years. Include any coverage which may be directly related or respond in part to the exposure for which you are applying for coverage under this application:

Company	Limit	Deductible	Premium	Policy Term

Has any application for similar insurance made on behalf of any you or any of your predecessors in business or their present partners, owners, officers, sales personnel or employees ever been declined or has any such insurance ever been canceled or refused renewal?
Yes No

If Yes, please give details.

Provide the following information for General Liability Coverage currently in force:

Company	Limit	Deductible	Policy Term

Does the policy above include coverage for Products/Completed Operations Hazards? Yes No

Proposed Description of Services
In this section you are being asked to describe the services you want to insure as you would like them to appear on the policy under "Schedule of Insured Services". Your suggested wording will be considered by us, but is subject to change based on underwriting requirements or may be further negotiated. Your proposed wording is not an insuring agreement. Proposed Schedule of Insured Services:

Limit of Liability desired:
Deductible:

Representations

By submitting this application, you agree that:

A. The statements and answers given in this application and any attachments to it are accurate and complete;
B. The statements and answers you furnished to us are representations you make to us on behalf of all persons and entities proposed for coverage;
C. Those representations are a material inducement to us to provide a proposal for insurance;
D. Any policy The Zutz Group issues will be issued in reliance upon those representations;
E. You will report to us immediately, in writing, any material change in your operations, condition or answers provided in this application that occur or are discovered between the date of this application and the effective date of any policy, if issued; and
F. Upon receipt of any such notice, The Zutz Group reserves the right to modify or withdraw any proposal for insurance we have offered.

Additional Comments

WARNING

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING any MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND IN NEW YORK SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.

Please click the "Submit Quote" button to send your quote request.
This is a request for quotation only. No coverage is in effect until bound by an insurance carrier.

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