Errors and Omissions Insurance Quote

Errors and Omissions Insurance
Quote

COPIES OF THE FOLLOWING INFORMATION MUST BE INCLUDED WITH THIS FORM Resumes of principals, partners and senior staff. Brochures and/or promotional literature. A copy of a representative contract and/or letter of agreement (including the scope of services) used by your firm. Please answer all questions on this form, print it out, sign it, and mail to us with the above information. If there is no answer for a particular question, write "none" or "not applicable" in the space.

CONTACT INFORMATION
Surname: *		First Name:
Telephone:
E-mail: *

FIRM INFORMATION
Firm Name:
Address:
City:
Province: *			Postal Code:
Location of Branch Offices:
Date operations began: (mm-dd-yyyy)
Please provide a complete description of the Applicants activities and provide definitions for uncommon terms:
To whom does the Applicant provide services:
Applicants gross annual fees or Income: Last year $		Total anticipated fees for next year: $
Does the Applicant provide services or perform activities outside Canada or for clients who are outside Canada Yes No If yes, provide details:
Provide a breakdown of Applicants fees by category of services:
Type of Service		% (total must be 100%)




Please indicate areas of concern which prompted the need for insurance protection:
What safeguards or procedures does the Applicant employ to avoid such losses.
Indicate total number of employees
Professional: Clerical:		Other (specify)
Complete the following for any person performing professional duties:
Name	Duties	Education	Years of Exp.

Does the applicant belong to any related association:		Yes No
If yes, list associations:
Has the Applicant ever been investigated by or suspended from practice by any governing body of his/her profession?		Yes No
If yes, provide details:
Is any legislation currently in force governing the practice of the Applicant?		Yes No

INSURANCE COVERAGE
Has the Applicant ever previously purchased professional or errors and omissions insurance?		Yes No
If yes, give details of Insurer, Period, Expiring Premium, Limit and Deductible:
Has insurance coverage ever been declined or cancelled or renewal thereof been refused?		Yes No

LOSS EXPERIENCE
In the past, has the Applicant or any of his/her employees ever been the recipient of any allegations of professional negligence in writing or verbally?		Yes No
Is the Applicant or any of his/her employees aware of any facts, circumstances or situations which may reasonably give rise to a claim, other than as advised above?		Yes No

LIMITS REQUESTED
Per claim:	Per Policy Period:
Deductible:
REMEMBER TO ATTACH THE FOLLOWING INFORMATION Resumes of principals, partners and senior staff. Brochures and/or promotional literature. A copy of a representative contract and/or letter of agreement (including the scope of services) used by your firm.
______________________________________ Date ______________________________________ Signature ______________________________________ Title

INSTAR Insurance Brokers Inc.
2435 Holly Lane, Suite 200
Ottawa, Ontario K1V 7P2

Toll Free: 1-888-769-9299
Local: (613) 228-1600
Fax: (613) 232-6486
info@instar.on.ca