Management/Marketing Consultant's Professional Liability
Date: 
Section I - Background Information
1. Name of Insured: 
2. Address: 
  City, State, Zip: 
  Website: 
3. Limits of Liability Desired:   $250,000   $500,000   $1,000,000
4. Deductible:   $1,000   $2,500   $5,000   $10,000
5. Date Established: 
6. Is Insured:   Individual   Corporation   Partnership   Other: 
7.  Is the Applicant controlled, owned, affiliated or associated with any other firm, corporation or company? 
    Yes    No
8.  Does the Applicant have any subsidiaries?  Yes    No
   If Yes, please list on a separate sheet of paper and advise if coverage is to apply to them.
9.  During the past five years has the name of the firm been changed or has any other business been acquired,
   merged into or consolidated with any other firm, corporation or company?  Yes    No
(If Yes, please attach an explanation and advise if any liabilities have been assumed as a result of the merger, acquisition or consolidation)
Section II - Organization Operation Details
10.  Please describe in detail the professional services for which coverage is desired:
   
11. (a)  List total gross receipts derived from activities in question #10:
     Last Year:  
     Current Year (based on twelve months):  
     Forcast for Next Year:  
  (b)  Does the Applicant receive any compensation other than money (stock, options...) for providing professional
     services?  Yes    No     If Yes, advise details: 
12. (a)  Does the Applicant derive income from any activity or profession other than what is described in question #10?
      Yes    No     If Yes, please attach an explanation and estimated receipts (advise if these receipts were included in question #10).
  (b)  Is the Applicant a licensed professional (i.e. Lawyer, Accountant...)?  Yes    No 
     If Yes, advise type of license professional: 
13. (a)  Describe the five (5) largest jobs or projects during the past 3 years:
    Name of Client Services Provided Gross Billings/Fees  
     
     
     
     
     
  (b)  Was more than 50% of Applicant's total gross billings for any one year derived from a single client or contract?
      Yes    No     If Yes, specify client, services rendered and how long relationship is expected to continue:
     
  (c)  Describe any jobs or projects anticipated during the next 12 months that will result in 10% of Appllcant's
     gross receipts (not already listed in #13a):
     
14. (a)  Advise the number of principals, partners, officers, and professional employees directly engaged in providing
     services to clients: 
  (b)  Advise the number of all other (non-professional/clerical) employees: 
  (c)  Advise the number of independent/sub-contractors doing work on your behalf: 
15.  Does the Applicant desire to provide coverage under this Policy for independent/sub-contractors doing work on
   their behalf?   Yes    No     If Yes, advise on a separate sheet:
  (a)  How the Applicant utilizes each independent/sub-contractor.
  (b)  The total percentage of Applicant's work done by independent/sub-contractors.
  (c)  Does the Applicant require Certificates of Insurance from all independent/sub-contractors?
16.  Please provide the following (attach a separate sheet if necessary):
  Name of all Partners, Principals,
Key Employees and
Independent/Sub-Contractors		 Professional
Qualifications/
Designations		 # of Years in Practice # of Years with Applicant
 
 
 
 
 
17.  Does the Applicant design, manufacture or test any product or process for creating a product?
    Yes    No     If Yes, provide details on a separate sheet.
18.  Does the Applicant use a written contract with clients?   In all cases    Sometimes    Never
19.  Has the Applicant or Independent Contractor ever been dismissed from a project or contract prior to completion?
    Yes    No     If Yes, provide details on a separate sheet.
20.  Has the Applicant ever ever entered into contracts where fees were obtained by the client achieving certain
   cost reductions or results in general?   Yes    No     (If Yes, please attach explanation).
21.  Does any director, officer, employee, partner or independent/sub-contractor of the Applicant serve on the Board
   of Directors of any client or own any financial or equity interest in any client of the Applicant?   Yes    No
 If Yes, please attach explanation.
Section III - Claims Information
Do not complete this section if this is an application for a renewal policy at the same limit of liability with one of the USLI companies.
22.  During the past five (5) years, has any claim been made or suit brought against the agency, its predecessor(s)
   in business, or any of its present or former owners, partners, officers, directors, employees, or independant/sub-contractors?   Yes    No     (If Yes, please provide details on the separate supplemental claims application).
23.  Is any owner, partner, officer, director, employee, or independant/sub-contractor aware of any circumstance,
   allegation, contention, or incident which may result in a claim being made against the agency, its predecessor(s) in business, or any of its present or former partners, owners, officers, directors, employees, or independent contractors?   Yes    No     (If Yes, please provide details on the separate supplemental claims application).
Section IV - Professional Liability Insurance Coverage
24.  Has any Policy of or Application for professional liability insurance on your behalf or on the behalf of any of your
   principals, officers, employees, or on the behalf of any predecessor(s) in business ever been declined, canceled or refused renewal?   Yes    No     If Yes, advise details:
   
25.  Is similar professional liability insurance currently in force?   Yes    No     If Yes, please advise:
  Name of Carrier Limit Deductible Premium Policy Period
 
  Retroactive Date, if any:  
  Length of time coverage has continuously been in force:  
Section V - General Liability Information
26.  Does the Applicant currently have General Liability Insurance?   Yes    No    If Yes, Please advise:
  Carrier Premium Expiration Date GL Losses
   Yes    No
   Describe any General Liability Losses in the past 5 years:
   
27.  Number of employed consultants: 
28. (a)  Does the Applicant use Independent Contractors?  Yes    No   If Yes, please answer 28(b) and (c).
  (b)  Is General Liability coverage to include Independent Contractors?  Yes    No
  (c)  Number of Independent Contractors used: 
29. (a)  Is the Applicant involved in the installation of equipment or physical application of the items for which they are
     providing consultation services (including work done by Independent Contractors supplied by the Applicant)? 
      Yes    No   If Yes, please answer 29(b) and (c).
  (b)  Describe installations or applications:
     
  (c)  Costs of sub-contracted work: 
     Are subcontractors required to have liability insurance?  Yes    No
     Are Certificates of Insurance maintained by the Insured?  Yes    No
30.  Additional Insureds to be included (list Name, address, and relationship to Applicant):
   
Section VI - Personal Property Insurance Information
31. (a)  Personal Property Limit Needed (at 80% Coinsurance/Replacement Cost): 
     If Limit is greater than $25,000, please answer 31(b) and (c) below:
  (b)  Protection Class (1 through 10): 
  (c)  Burglar Alarm:    Yes    No   Central Station:    Yes    No 
     Sprinklers:    Yes    No   Central Station:    Yes    No 
     Fire Alarm:    Yes    No   Central Station:    Yes    No 
32.  If located in first tier coastal county, distance from water (ocean, bay or inlet): 
33.  Previous Carrier:   Expiration Date:   Premium: 
34.  Property claims paid or pending during last five years:
   
Section VII - Consulting Information
ALL QUESTIONS MUST BE ANSWERED AND APPLICATION MUST BE SIGNED BY APPLICANT.
35.  Does the Applicant design, manufacture or test any product or process for creating a product?  Yes    No
   If yes, please advise details:
36.  Does the Applicant plan to or has the Applicant within the past five (5) years:
  a)  Consulted on mergers, acquisitions, capitalization, or liquidation's?   Yes    No
b)  Prepared, reviewed or apprived achitectural, engineering or construction maps, plans,  
   opinions, estimates, surveys, designs or specifications or otherwise been involved with  
   the design, construction, demolition or testing of any building structure?   Yes    No
c)  Primary activity is to consult on downsizing or rightsizing.   Yes    No
d)  Been involved in any financial or environmental consulting?   Yes    No
e)  Been involed in the management, purchase, sale or development of any real estate?   Yes    No
37.  Please indicate the percentage of Applicant's annual revenue from the last fiscal period involving:
   (Total must equal 100%)
   Executive Search/ Recruiting  %   Attitude and Opinion Surveys  %
   Human Resource Consulting  %   Competitive Analysis  %
   Education/Training  %   Customer Service  %
   Quality Improvment/Quality Control  %   Mailing List/Telemarket List Development  %
   Business Communication  %   Marketing Research  %
   Administrative/Office Services  %   Telemarketing Sales  %
   New Product Marketing  %   Downsizing/Rightsizing Planning  %
   Feasibility Studies  %   Financial Planning  %
   Management Audits  %   Long Term Projects/Planning  %
   Management/Owner Succession Planning  %   Mergers and Acquisitions  %
   Computer Consulting  %   Product Testing  %
38.  Does the Applicant provide any service other than those services listed above in #3?  Yes    No
   If yes, please provide details on a separate sheet.
 
Section VIII - Required Information
    Please submit each of the following items with the Submission:
  A.  USLI Application.
  B.  Copy of Financial Statement.
  C.  Copy of Applicant's formalized standard client contract.
  D.  Copy of resumes on technical and key personnel.
  E.  Marketing materials/brochures.
 
FRAUD STATEMENT: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON, FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.
 
THE STATES OF FLORIDA AND NEW YORK REQUIRE THAT WE HAVE THE NAME AND ADDRESS OF YOUR (INSURED'S) AUTHORIZED AGENT OR BROKER.
Name of Authorized Agent or Broker 
Address 
License No. 
Mail completed
application through
local agent or
broker to:
Notice to the Applicant
The undersigned declares that to the best of his/her knowledge and belief the particulars and statements set forth herein are true and agree that those particulars and statements are material to the acceptance of the risk assumed by the Company. The undersigned further declares that any claim, incident or event taking place prior to the effective date of the insurance applied for which may render inaccurate, untrue or incomplete any statement made will immediately be reported in writing to the Insurer and the Insurer may withdraw or modify any outstanding quotations and/or authorization or agreement to bind the insurance. The Insurer is hereby authorized, but not required to make an investigation and inquiry in connection with the information, statements and disclosures provided in this Application. The decision of the Insurer not to make or to limit any investigation or inquiry shall not be deemed a waiver of any rights by the insurer and shall not stop the Insurer from relying on any statement in this Application. The signing of this Application does not bind the undersigned to purchase the insurance, nor does the review of this Application bind the insurance company to issue a policy. It is understood the Insurer is relying on this Application in the event the policy is issued. It is agreed that this Application shall be the basis of the contract should a policy be issued and it will be attached and become part of this policy.


 Signature of Applicant or Insured: _______________________________________________   Date: __________
Must be signed by a Principal, Partner or Officer of the Firm.

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