YesNo
YesNo

Organization Information

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FPNPGPLPLLCFP=For Profit, (other than Partnership); NP=Non-Profit; GP=General Partnership; LP=Limited Partnership; LLC=Limited Liability Company

In the next 12 months(or during the past 24 months) is the Applicant contemplating (or has the Applicant completed or been in the process of completing) the following:

YesNoYesNoYesNoYesNoYesNo

Describe, in detail, all professional services offered by the Applicant:

Indicate Applicant’s revenue for the following years:

Describe the Applicant’s 5 largest projects or jobs during the past 3 years:

YesNo
YesNo

If Yes, please attach a sample. If No, please attach an explanation detailing how responsibilities are defined between the applicant and client.

YesNo

If Yes, please attach an explanation.

Does the applicant use:

YesNoYesNo

Indicate the number of Applicant’s employee:

Indicate the following information for all Principals/Partners, Officers, and professional employees.

Current Insurance Information/Requested Insurance Terms:

YesNoYesNo
Duty to DefendReimbursement

Loss Information

YesNo

If Yes, please attach an explanation

With respect to the information required to be disclosed in response to the question above, the proposed insurance will not afford coverage for any claim arising from any fact, circumstance, situation, event or act about which any executive officer of the Applicant had knowledge prior to the issuance of the proposed policy, nor for any person of entity who knew of such fact, circumstance, situation, event or act prior to the issuance of the proposed policy.

Loss Information

YesNo

If Yes, please attach an explanation

YesNo