Forensic Consultants Professional Liability

FORENSIC LITIGATION CONSULTANTS PROFESSIONAL LIABILITY
(This is an application for claims made coverage)

A) Please 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.
D) - PLEASE TYPE -

1. Name of Applicant (Mr. Ms. Dr.): *

Applicant is

Partnership

Individual

Corporation

Other (please specify) Other (please specify)

Physical Address *

City *

State *

Zip Code *

Area Code/Phone Number

Fax Number

Mailing Address

Email Address

2. List Branch Offices and Addresses, if any

3 a) Is your forensic work done on a full or part-time basis?

Full-time

Part-time

If Part-time, do you work full-time?

Yes

No

What is your occupation?

Annual income from full-time occupation

0 - $20,000

$20,001 - $40,000

$40,001 - $60,000

Over $60,000

Gross income from full-time occupation for past three (3) years:

0 - $20,000

$20,001 - $40,000

$40,001 - $60,000

Over $60,000

3 b) State gross income derived from services as Forensic Litigation Consultant for past year:

State gross income derived from services as Forensic Litigation Consultant for current year:

State estimated gross income derived from services as Forensic Litigation Consultant for next year:

4. Total number of consultations, cases and/or files handled annually for past three (3) years

Concerning the above, how many result in court appearances?

5. Please provide the following information:

List names of all Forensic Litigation Consultants providing professional services on behalf of the Applicant: (If contractors, please state number of hours they performed these services for the Applicant in the past 12 months)

6. How many years has the Applicant been providing services as a Forensic Litigation Consultant?

7. What is the Applicant's area of expertise?

Please furnish background information on this area of expertise (use a separate attachment if necessary).

8. a) Please list membership in any professional association.

b) Qualifications (including licenses and professional designations)

c) Can you confirm you have all required licenses and qualifications to carry out the areas of your expertise?

Yes

No

d) I hereby affirm that all required licenses for the practice of my profession under this insurance will remain current (in force) during the currency of this policy for which I am applying. I further understand and agree that I shall have no coverage for any professional services rendered at any time that any required or applicable license is not valid or in good standing.

Yes

No

9. Please provide a detailed description of a common forensic case that you have worked on. (use a separate attachment if necessary).

10. Does the Applicant maintain any other type of professional liability insurance?

Yes

No

If Yes, please furnish for the past three (3) years:

Type of Coverage:

Name of Carrier:

Limits of Liability:

Policy Period:

Type of Coverage

Name of Carrier:

Limits of Liability:

Policy Period:

Type of Coverage

Name of Carrier:

Limits of Liability:

Policy Period:

11. a) 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 an expert witness or forensic consultant:

Yes

No

If yes, please provide full particulars (use a separate page if necessary):

0/450 characters

11. b) 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?

Yes

No

If yes, please provide full particulars (use a separate page if necessary):

0/450 characters

11. c) Have all claims and circumstances requiring a response in questions 11a) and 11b) already been reported to and accepted by a current or past Insurer?

Yes

No

If no, please provide full particulars (use a separate page if necessary):

0/450 characters

12. 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 an expert witness or forensic consultant ever been canceled or declined or refused renewal?

Yes

No

If yes, please provide full particulars (use a separate page if necessary):

13. Limits of Liability Requested:

$100,000 / $100,000

$250,000 / $250,000

$500,000 / $500,000

$1,000,000 / $1,000,000

Deductible Requested:

Please send a copy of resume(s).

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.

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.

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.

Title

Electronic Signature /s/ *

Date Signed * +

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 bind or obligate the Applicant or Underwriters to complete this insurance.