FIDUCIARY PROFESSIONAL LIABILITY INSURANCE
CLAIMS MADE COVERAGE APPLICATION
1.
Business Name:
(Named Insured on Policy)
a.
Address:
Address, City, State
Zip
Website
b.
Contact:
First Name
Last Name
Phone
c.
Business:
Founded Date
as
SP
GP
LLP
PC
LLC
Other
d.
Headcount and Roster:
Professionals:
Support Staff:
Professional's Name
Licenses\Certificates\Memberships
Hire Date
Please list any additional Professional Staff in question 6 below.
2.
Gross Billings Details:
a.
Provide Applicant's annual gross billings, whether received or not (If Applicant is a startup, please estimate Applicant's first year's gross billings):
b.
Provide the number of clients you serve in each of the following areas (without double counting matters and if multiple categories apply per client, count the area generating the highest revenue):
Guardian*
Conservator*
Executor
POA Agent
Trustee
Trust Protector
Rep. Payee
DMM*
Care Manager
Receiver
Other+
*Guardian - of the Person (including Ad Litem); Conservator - of the Estate; DMM - Daily Money Manager.
+If Other, explain:
c.
List the states and counties in which your clients reside:
3.
List below any other professional liability insurance Applicant current has, if any, and indicate desired limit for current coverage:
Carrier
Incept
Expiry
Retro*
Limits
Deductible
Desired Coverage:
$250k/$250k
$250k/$500k
$500k/$500k
$500k/$1mil
$1mil/$1mil
$1mil/$2mil
$2mil/$2mil
*Note:
Your *Retro(active) date normally matches the date you first began uninterrupted liability coverage.
4.
With respect to matters involving professional services rendered in a fiduciary capacity:
a.
what percentage involve health care decisions?
b.
what percentage involve your client's business assets (i.e. rental properties, restaurants, etc.)? If any, explain in question 6.
c.
what percentage are court appointed?
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d.
Please list below Applicant's top two (2) conservatorships, guardianships, trusts, estates, powers of attorney (POA) or similar fiduciary matters by gross assets under your control (rounded to the nearest $100,000).
Conservatorship, Guardianship, Trust, Estate, POA, or Other Matter Name
Gross Assets Controlled ($)
5.
Within the past five (5) years has Applicant or any of its current or past professional or other money-handling staff:
a.
participated as an owner, officer, director or employee of any other business, company, trade or profession?
Yes No
b.
handled any cases without written documentation of Applicant's scope of services and authority?
Yes No
c.
acted in a co-trustee/co-agent capacity?
Yes No
If yes, provide name and relationship:
d.
been appointed the successor to a fiduciary who was terminated for cause?
Yes No
e.
brought any suit for the collection of professional service fees?
Yes No
f.
maintained any branch offices/separate mailing addresses?
Yes No
g.
performed professional services for a family member?
Yes No
h.
contracted family members to serve clients?
Yes No
i.
been subject to any liability claim arising out of the rendition of professional services?
Yes No
j.
become aware of any pending:
i.
demand that any of its bonds be surcharged?
Yes No
ii.
objection to an accounting issued by the Applicant?
Yes No
iii.
demand for a reduction or waiver of the Applicant's fees?
Yes No
iv.
demand that Applicant be removed for cause from any professional roles?
Yes No
v.
circumstances which may result in a claim against Applicant, a predecessor or member?
Yes No
k.
been accused of or charged with any crime or offense involving fraud or deceit?
Yes No
l.
had a liability policy cancelled or non-renewed by an insurer?
Yes No
m.
been subject to a surety company bond surcharge?
Yes No
n.
been subject to professional discipline?
Yes No
6.
Please confirm applicant has provided the additional information as requested below:
Yes No
a.
Explain all 'Yes' responses within question 5
b.
For Predecessors in Business, please provide the firm name and dates of operation.
c.
For Additional Insureds required by contract or law, please provide the name, address, and relationship to Applicant.
Additional Information:
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By and through the undersigned, Applicant acknowledges, agrees and declares to the best of its knowledge and belief that:
The information set forth herein is true and any change in circumstances prior to the effective date of the insurance applied for, which may render inaccurate, untrue, or incomplete any statement or disclosure made herein, will immediately be reported in writing to underwriters who may in turn withdraw or modify any outstanding offer of insurance;
Underwriters are hereby authorized, but not required, to make an investigation and inquiry in connection with the information provided in this application, understanding that any failure to do so shall not abridge any such rights nor estop underwriters from relying upon any of Applicant's representations herein;
The submission and review of this application shall not serve to bind Applicant to purchase, nor underwriters to issue, any policy of insurance;
In the event that an insurance policy is issued to Applicant, in doing so, underwriters shall be entitled to rely upon all material representations contained within this application which forms the basis for such insurance and shall be attached to and become a part of any such policy;
Subject to all other policy terms and conditions, coverage under any policy issued will only apply to claims first made against Applicant and reported to underwriters during the policy period, or extended reporting period;
Subject to all other policy terms and conditions, the limit of liability available to pay damages shall be reduced and may be completely exhausted by payment of claims expenses; moreover, damages and claims expenses shall be applied against the applicable deductible;
Any person who knowingly and with intent to defraud files an application for insurance containing any materially false information, or for the purpose or misleading conceals any material fact, may be held criminally liable depending upon the laws of the applicable jurisdiction; moreover, any misrepresentation or misstatement of material facts may void coverage under the proposed insurance; and
Pursuant to the provisions of the Electronic Signatures in Global and National Commerce Act (E-SIGN, 2000) and the Uniform Electronic Transactions Act (UETA, 1999), execution of this application form by means of typing ones name, title and date below carries the same weight and legal effect as traditional paper documents and handwritten signatures.
/s/
Electronic Signature
Signer's Title
Date Executed
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