Hubbard Insurance Brokers Inc.
100 Matheson Blvd E., Suite 103
Mississauga, ON L4Z 2G7
(905) 712-4668 fax: (905) 712 3586
email: admin@hubbardinsurance.com

Tuesday, 06 January 2009

SITE GUIDE:

Outlined below is some of the information we will need to obtain a quote on your behalf, but every business is different and this is the starting point.
Please print this form out, complete and sign it, and then fax it back to us.

Application for
Errors & Omissions/Professional Liability Insurance

Name of Applicant: _______________________________________
If different from above, state Name
under which business/practice is conducted: ___________________________________________
Select Ownership Type: Corporation or Partnership or Individual
Date Firm Established: _____________________ Number of years under present ownership: ___________________
Address of Main Office: _________________________________________________
Address(es) of Branch Office(s):
_____________________________________________________________
_____________________________________________________________
Please give a full description of your operations:
_____________________________________________________________
_____________________________________________________________
Are your operations controlled, owned for associated with any other Firm, Corporation or Company?
If "YES", please provide full details:
_____________________________________________________________
_____________________________________________________________

Please provide the following:

Name in full of all Pricipals/Owners	Qualifications	Date Qualified	Length of Time in Practice	Length of Time as Partner/Principal
____________	____________	____________	____________	____________
____________	____________	____________	____________	____________
____________	____________	____________	____________	____________
____________	____________	____________	____________	____________

Indicate the total number of employees:

Professional: ____________

Sales Representative: ____________

Clerical: ____________

Other: ____________

(Please elaborate upon the duties rendered by those employees where Professional or Errors & Omissions coverage would apply. Such information should be supplied on a separate page.)

Explain fully the EDUCATIONAL REQUIREMENTS for your Profession:
_____________________________________________________________
_____________________________________________________________
Does the Applicant belong to any related associations? YES NO
If answer to a) above is "YES", please indicate such memberships:
_____________________________________________________________
_____________________________________________________________
Are there any specific prerequisites for association eligibility?
If so, please provide details:
_____________________________________________________________
_____________________________________________________________
Has the Applicant ever been investigated by or suspended from practice by any body governing the practice of his/her profession? YES NO
If the Applicant answered "YES" above, please provide full details of such investigation or suspension.
_____________________________________________________________
_____________________________________________________________
Is any LEGISLATION currently in force governing the practice of the Applicant? YES NO

Please give the following details of all Errors & Omissions or Professional Liability Insurance carried in the past 3 years:

Insurer	Period	Limit	Deductible	Claims or Occurrence Basis
____________	____________	____________	____________	____________
____________	____________	____________	____________	____________
____________	____________	____________	____________	____________

During the past 5 years, has the Applicant had similar insurance declined, cancelled or refused? YES NO
If so, please give details.
_____________________________________________________________
_____________________________________________________________
During the past 5 years, have the Applicant, Partners, or Principals had one or more claims because of professional services, or is the Applicant, Partners, or Principals aware of any facts or circumstances or allegations which may give rise to a claim? YES NO
If so, please give details.
_____________________________________________________________
_____________________________________________________________
Indicate your business' gross annual fees or income for the past year: ____________________________________

and anticipated for next year: ____________________________________
What proportion of your fees or income is derived from clients outside Canada. (Please give percentage for each country).________________________________________________________________________
Limits of Liability Requested:
Per Occurrence: $ ____________________________________
Aggregate: $ ____________________________________
Deductible Requested: $ ____________________________________
DECLARATION:
The undersigned declares that to the best of his/her knowledge the statements made in the Application and the information contained in documents submitted with it are true. Signing of this document does not bind the Applicant to complete the insurance, but it is agreed that the Application shall be the basis of the contract, should a policy be issued, and it will be attached to and become part of the policy.
Signed: ____________________________________
Name: ____________________________________
Title/Position: ____________________________________
Phone Number: ____________________________________
EMail Address: ____________________________________

HUBBARD INSURANCE BROKERS
100 MATHESON BLVD. E.
SUITE #103
MISSISSAUGA, ONTARIO
L4Z 2G7
PH# (905) 712-4668
FAX# (905) 712-3586