INHOUSE SAFETY PROFESSIONALS
PROFESSIONAL LIABILITY INSURANCE
issued to the
AMERICAN SOCIETY OF SAFETY ENGINEERS
and
SPECIFIED MEMBERS
(This is an application for claims made coverage)

A) Please PRINT or TYPE answers to all questions, leaving no blank spaces.
B) The application must be signed and dated.
C) When answering questions, please use a separate sheet of paper if space provided is insufficient.
 
calendar

2) Please describe areas of work below by showing the percentage of work time derived from each and a brief description of each, please use a separate sheet of paper if necessary.

Example: 30%  Description: OSHA Compliance.  I/we provide OSHA Compliance audits for industrial clients, mostly chemical manufacturers.

= 100% TOTAL
3b) Do you only make observations and recommendations with regard to safety issues?
Or
Do you ever have the authority to direct the implementation or correction of safety procedures and/or violations?
4) What percentage of your clients are in the following industries totaling 100%? 
0/100 points
5a) Have any safety related claims or suits been made during the past five years against the Applicant or the Employer?
5b) Is Applicant aware of any circumstances which may result in a claim?
6a) Does the Applicant presently have a professional liability policy?
6b) Does the Applicant's Employer presently have a professional liability policy or Errors and Omissions insurance?
6c) Does the Applicant's Employer presently carry Workers Compensation insurance?
7) Has any similar insurance for the Applicant ever been canceled or declined?
8) Limits of Liability Requested:
Deductible Requested:
9) Are safety services provided on a full-time basis or part-time basis.
10) Please provide the following information, use a separate sheet of paper if necessary:
 Name of All Partners/Principals; Key EmployeesPositionHow long as Partner/Principal; Key EmployeeMember of ASSE? Y/N
.
.
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PLEASE ATTACH A RESUME FOR EACH OF THE ABOVE.

 

I hereby declare that the above statements and particulars are true, and that I have not suppressed or misstated any material facts.  At the present time, I have no reason to anticipate any claim being brought against me for any act, error, or omission on my part, other than as stated above, and agree that this Proposal Form shall be the basis of the contract between me and the Underwriters and shall be deemed a part thereof.

This proposal form duly completed, together with any supplementary information, must be signed in ink by the Applicant.  A signed copy will be attached to and form part of the policy or certificate, if issued.  Completion of this proposal form does not obligate the Applicant or the Underwriter to complete this insurance.

 AIF 2353 A (03/08)