ASSE Professional Liability and Commercial General Liability Insurance
(Application follows)

The coverage for which you are applying is an Annual policy.  The Professional Liability is written on a “Claims Made” basis.  This means that the act, error or omission has to occur after the Retroactive Date and the Policy has to be in force at the time that the claim is made.  The General Liability is written on a "Per Occurrence" basis - i.e., it responds to claims arising from occurrences which take place during the policy period - regardless of when the claim is made.

 
If your expiring General Liability policy was written on a "Claims Made" basis, you will need to contact that broker to find out what your options may be with regard to "tail" coverage for that policy. (Please note there is usually only a short time frame during which this "tail" coverage is available for purchase when the policy is expiring.)
 
The application attached becomes a part of your ASSE Professional and/or General Liability policy. Unless otherwise noted or advised, coverage under the policy extends only to the activities you list (unless changed by endorsement) - so it is very important you accurately and completely describe the work to be covered by these policies.
 
The ASSE General Liability policy excludes professional services – an essential part of your insurance coverage. Therefore, in order to bind any ASSE General Liability coverage, Underwriters require you also maintain the ASSE Professional Liability insurance in equal or greater limits.
 
It is preferable any subcontractors you use maintain their own professional and general liability insurance in limits at least equaling yours and name you as an additional insured under their policy. We do have an Additional Insured Form attached which may be used to request additional insured status for your clients or subcontractors. That coverage is provided only to the extent that liability arises out of your conduct as the Named Insured.
 
Watch the wording of your client's contracts! The ASSE General Liability policy provides coverage only with respect to your work and to the extent the same liability would exist in the absence of a contract. It does not cover contractual indemnification requirements nor cover you for failure to maintain a client's insurance requirements. For this reason, it is especially important for you and/or your attorneys to review the contractual and indemnification section of your clients contracts to make sure you are aware of the liabilities you may be assuming and request changes as necessary.
 
The GL insurance policy provides only General Liability coverage. Thus for example, the General Liability policy will not provide coverage for the following:
                        
                                    *Automobile Liability (Owned, Non-owned or Hired)
                                    *Workers Compensation
                                    *Employers Liability
                                    *Stop Gap Coverage
                                    *Professional Liability
                                    *Your Personal Business Property
 
Some of these coverages may be available to us through other markets in certain states. If you are in need of them, let us know. In closing, we look forward to working with you. If you have any questions about the application or the coverage, please feel free to give us a call.
 
 

AMERICAN SOCIETY OF SAFETY ENGINEERS
PROFESSIONAL LIABILITY AND COMMERCIAL GENERAL LIABILITY
(Specified Members of American Society of Safety Engineers)
Application for “Claims Made” Professional Liability and “Occurrence” Commercial General Liability

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 attachment if space provided is insufficient.
APPLICANT INFORMATION:
(c) Applicant is:
 
f) Do you work from home or a dedicated office?
(e) Any operations sold, acquired, or discontinued in the last five years?
(f) Number of employees:
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h) Total Gross Receipts (whether collected or not) from Billable Hours:
 -
This Year (Estimate): $
Last Year: $
Two Years Ago: $

2a) Please describe areas of consulting services below by showing the percentage of income derived from each and a brief description of each, please use a separate attachment if necessary.

Example: __30___%  Description: OSHA Compliance.  I/we provide OSHA Compliance audits for industrial clients, mostly chemical manufacturers.

2b) Does the Applicant perform Onsite Safety Surveys/Inspections/Audits?
2c) Do you perform any Safety Consulting activities offshore or overseas?

2d)  What percentage of your Surveys/Inspections/Audits are:

4) What percentage of the Applicants clients are in the following industries totaling 100%? 
0/100 points
ADDITIONAL INSUREDS
 
5) Please complete attached Additional Insured request form, if applicable.
PREVIOUS INSURANCE AND LOSS HISTORY
6a) Professional Liability:
Does the Applicant presently have a professional liability policy?
6b) Please give details of previous professional liability policies purchased in the last five years by the Applicant or predecessor or prior entity.
 CarrierLimitsDeductiblePaid PremiumsCoverage Dates Effective From - To
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6c) Commercial General Liability

Please provide carrier information for the last three years:

 Expiration DateCarrierPolicy NumberPolicy TypeGeneral AggregateProducts AggregatePer OccurrenceTotal Premium
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7a) Have any claims or suits been made during the past five years against the Applicant, or any person now a principal or owner of the Applicant, or any predecessor entity or any prior entity owned or previously owned by a current principal or owner of the Applicant either as an individual or as a safety consultant:
7b) Upon inquiry of all personnel, is the Applicant, or any employee, manager or owner of the Applicant, aware of any circumstance, incident or situation, which may result in a claim?
7c) Have all claims and circumstances requiring a response in questions 5a) and 5b) already been reported to and accepted by a current or past Insurer?

If no, please give full details on a separate attachment.

7d) Has any similar insurance for the Applicant or any person now a principal or owner of the Applicant, or any predecessor entity or any prior entity owned or previously owned by a current principal or owner of the Applicant either as an individual or as a safety consultant ever been canceled or declined or refused renewal?
8) Does the Applicant always provide clients with contracts and disclaimers?
9) Does the Applicant use a contract to limit the exposure?
10) Are safety consulting services provided on a full-time basis or part-time basis
12a) Number of employees:
12b) Please provide the following information, use a separate attachment if necessary:
 Name of All Partners/Principals; Key EmployeesPositionHow long as Partners/ Principals, Key EmployeesASSE Membership NumberProfessional Designations
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PLEASE ATTACH A RESUME FOR EACH OF THE ABOVE.

13a) Limits of Liability Requested:

       Professional Liability:

General Liability
13b)        Deductible Requested for Professional Liability:
 
If a deductible greater than $7,500 is chosen, a copy of your latest financial statement may be required to bind coverage.

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 the Underwriters and me and shall be deemed a part thereof.

Pursuant to the provisions of the Electronic Signatures in Global and National Commerce Act (E-SIGN, 2000) execution of the application form by means of typing ones name, title and date below carries the same weight and legal effect as traditional paper documents and handwritten signatures.  Further, as a principal of Applicant, I confirm that I have authority to execute this application on behalf of Applicant.

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance 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.

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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.