INDIVIDUAL APPLICATION FOR "CLAIMS-MADE" E&O INSURANCE FOR LIFE AND 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out Section I, 'Applicant', where you will provide your name, office telephone, mailing address, fax number, and email. Ensure all information is accurate for effective communication.
3. Move 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', list your gross insurance revenue for the past 12 months and break it down into percentages for different categories such as Fixed Life and Property/Casualty Insurance Sales.
5. Proceed to Sections IV and V regarding claims and disciplinary actions. Answer truthfully as these responses may affect your eligibility for coverage.
6. Finally, review all sections for accuracy before signing at the end of the application. If submitting electronically, ensure you save your changes.

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