Professional Liability Application



Download Application:

Please download the Professional Liability application and save it to your computer. Then, once you have completed the form, return here, click "Yes", and upload your application.

If you have any questions you can reach us at 1-833-223-2248.

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NOTICE: THIS IS AN APPLICATION FOR A CLAIMS-MADE AND REPORTED POLICY WHICH, SUBJECT TO ITS TERMS AND CONDITIONS, ONLY APPLIES TO CLAIMS BOTH FIRST MADE AGAINST THE INSURED DURING THE POLICY PERIOD AND REPORTED TO THE COMPANY IN WRITING DURING THE POLICY PERIOD AND IN ACCORDANCE WITH THE POLICY’S REPORTING PROVISIONS. THE POLICY WILL OFFER AN EXTENDED REPORTING PERIOD THAT EXTENDS THE TIME TO REPORT CLAIMS FIRST MADE DURING THE POLICY PERIOD. AS WILL BE SET FORTH IN THE POLICY, THE LIMIT OF LIABILITY MAY BE REDUCED BY CLAIMS EXPENSES. THE APPLICANT AND ALL SIGNORS OF THIS APPLICATION WARRANT THAT THE INFORMATION CONVEYED IS TRUE AND CORRECT.