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:
Any actual or proposed merger, acquisition, or divestiture?*YesNoAny Creation of a new business, subsidiary, or division?*YesNoAny registration for a public offering or a private placement of securities?*YesNoAny reorganization or arrangement with creditors under federal or state law?*YesNoAny Branch, location, facility, office, or subsidiary closings, consolidations, or layoffs?*YesNo
Describe, in detail, all professional services offered by the Applicant:
Professional Services*% of Total Revenue*% of revenue Sub-contracted*
Indicate Applicant’s revenue for the following years:
Prior Fiscal Year*Current Fiscal Year*Estimation for next fiscal year*
Describe the Applicant’s 5 largest projects or jobs during the past 3 years:
Client's Name*Services Rendered*Annual Revenue Derived From the Project of Job*
If Yes, please attach a sample. If No, please attach an explanation detailing how responsibilities are defined between the applicant and client.
If Yes, please attach an explanation.
Does the applicant use:
A procedure manual?*YesNoA formal training Program*YesNo
Indicate the number of Applicant’s employee:
Principals/Partners, Officers, Professionals*Clerical/Non-Professional*
Indicate the following information for all Principals/Partners, Officers, and professional employees.
Current Insurance Information/Requested Insurance Terms:
Requested Limit($)*Requested Retention($)*Requested Effective Date*
Is the Applicant or any person proposed for this insurance aware of any fact circumstance, situation, event or act that reasonably could give rise to a claim against them under the Liability Coverage for which the Applicant is applying?*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.
Has any person or entity proposed for this insurance been a party to any professional liability claims, any disciplinary actions, or been cited by any regulatory agency or professional association during the past 5 years?*YesNo
Date of such claim*Nature of Claim*Amount paid for defense*
6060 N. Central Expressway Ste. 500, PMB327, Dallas, TX. 75206
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