AMERICAN SOCIETY OF SAFETY ENGINEERS
PROFESSIONAL LIABILITY
(Specified Members of American Society of Safety Engineers)
Application for “Claims Made” Policy

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.
 
c) Applicant is
 
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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 sheet of paper 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) 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
5a) Have any claims or suits been made during the past ten 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:
5b) 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?
5c) 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?
7a) Does the Applicant presently have a professional liability policy?
7b.) 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 FromCoverage Dates Effective To
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8) 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?
9) Limits of Liability Requested:
Deductible Requested:
 

If a deductible greater than $7,500 is chosen, a copy of your latest financial statement may be required to bind coverage.

10a) Does the Applicant provide clients with contracts, disclaimers, brochures or similar materials describing services?

IF YES, PLEASE PROVIDE A COPY OF EACH.
10b) Does the Applicant use a contract to limit the exposure?

IF YES, PLEASE PROVIDE A COPY.
11) Are safety consulting services provided on a full-time basis or part-time basis
12a) Total Gross Receipts (whether collected or not) from Billable Hours:
12b) Does any one client constitute 50% or more of the Applicants Gross Receipts?
14) Please provide the following information, use a separate sheet of paper if necessary:
 Name of All Partners/Principals; Key EmployeesPositionHow long as Partners/Principals; Key EmployeesASSE Membership Number
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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 the Underwriters and me and shall be deemed a part thereof.

The Applicant must sign this proposal form duly completed, together with any supplemental information, in ink. 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 2301 A (03/09)