INDIVIDUAL APPLICATION FOR "CLAIMS-MADE" E&O INSURANCE FOR LIFE AND 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out Section I, 'Applicant', which requires your name, office telephone, mailing address, fax number, and email. Ensure all information is accurate for effective communication.
3. Proceed to Section II, 'Insurance Coverage'. Indicate whether you currently have professional liability insurance and specify your desired policy inception date. Choose the coverage options that best fit your needs.
4. In Section III, 'Revenue', provide details about your gross insurance revenue from the past year. Break down this revenue into percentages based on the categories provided.
5. Complete Sections IV and V regarding claims and disciplinary actions. Answer truthfully as these responses affect your eligibility for coverage.
6. Finally, review all sections for accuracy before signing at the end of the document. If submitting electronically, ensure you save your changes.

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