(This is an application for a claims made policy 2026

1. Click 'Get Form' to open it in the editor.
2. Begin by entering the Legal Name of your Agency and any DBA (Doing Business As) names. Ensure all information is complete and legible.
3. Fill in your agency's address, including city, county, state, and zip code. Provide a contact name along with phone and fax numbers.
4. Indicate the type of applicant (Individual, Partnership, Corporation/LLC) and provide the establishment date along with years of experience.
5. List the total number of partners, staff, and office brokers. If applicable, indicate if you want to cover 1099 independent contractors under this policy.
6. Complete sections regarding ownership percentages and business placements. Ensure that totals equal 100% where required.
7. Provide revenue estimates for both the last 12 months and projections for the next year. Include details about current E&O carrier limits and deductibles.
8. Review all questions carefully, especially those regarding past claims or disciplinary actions. Provide detailed explanations on separate sheets if necessary.
9. Finally, sign the application as an owner or authorized representative to confirm that all information is accurate before submission.

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