Professional Liability (E&O) QUOTE Step 1 of 2 50% Applicant InformationName:* First Last Business Applicant Name:* Phone Number:*Email Address:* Applicant Website/URL: Type of Business Entity:*IndividualPartnershipCorporationLimited Liability CorporationLimited Liability PartnershipNon-Profit OrganizationSole ProprietorshipOtherDate Business Established:* MM slash DD slash YYYY Business InformationType of Business Service:If you do not see your profession listed please place in other. AdjustersAdministratorsAlarm MonitorsAnswering ServicesAppraisersArchitectsAssociation AccreditationAuctioneersAudio/Video ServicesBilling ServicesBookkeeping/Record KeepingCall CentersCollection AgenciesComputer ServicesConsultantsCourt ReportersCustoms BrokersDance InstructorsData ServicesDecorators/Interior DesignersDirectory PublishingDispute Resolution ServicesDocument ShreddersEmployment Agent/LeasingEngineersEntertainment ServicesEvent PlannersForeclosure AgentsFreight BrokersFuneral ServicesGraphic DesignersInsurance Agents/BrokersJanitorial ServicesLegal ServicesLiterary AgentsLoan ServicesMarketing ServicesMortgage BrokersNotaries PublicOffice ManagementPet-Related ServicesPhotographersPrintersProcess ServersPublic Relation ServicesReal Estate Agents/BrokersRelocation ServicesResearch OrganizationsSeminar ServicesTax CollectorsTax PreparersTrade Association ServicesTranslatorsTravel AgentsTutorsWeb DesignersOtherOther Type of Business Description of Professional Services Provided:*Current Year Gross Annual Revenues:*Prior Year Gross Annual Revenues:*Next Year (Projected) Revenues:*Total Number of Employees:*Number of Full-Time Employees:*Number of Part-Time Employees:*Does the Applicant Utilize the Services of Independent Contractors?* Yes No If Yes, Do you Require Independent Contractors to carry Professional Liability Insurance? Yes No What percentage of the time does the applicant use written contracts?*Please enter a number from 0 to 100.Have any Professional Liability Claims or suits been made against the applicant during the past five (5) years?* Yes No If YES, you will need to provide full details of any claim or suit. Is the applicant aware of any circumstances, alleged error or omissions, acts or situations which may reasonably be expected to result in a claim being made under the proposed insurance?* Yes No If YES, you will need to provide full details of any claim or suit. Please provide any detailed claim or potential claim information: Current Policy Expiration Date:* MM slash DD slash YYYY Current Insurance Carrier* Current Insurance Limits:*Select one$100,000/$300,000$250,000/$500,000$500,000/$500,000$500,000/$1,000,000$1,000,000/$1,000,000$2,000,000/$2,000,000$3,000,000/$3,000,000$4,000,000/$4,000,000$5,000,000/$5,000,000Current Insurance Deductible:*Select one$1,000$2,500$5,000$10,000$15,000$25,000OtherOther Current Deductible: Current Policy Retroactive Date:* MM slash DD slash YYYY Current Policy Premium:*