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Texas, Defense Base Act, DBA, Insurance, Financial, commercial gereral liability, property, workers comp, Texas Insurance and Financial Services, Inc., Auto, Cancer Insurance, Commercial, Crop, Health, Home, Life, Aircraft, Antique Auto, Boat, Jet Ski, Motorcycle, RV, Beekeepers, Consultants, Crop Insurance, Landscapers, Nurseries, Pilots, Ag Market News

Consultants Professional Liability Rate Request

Fields marked by an * are required.
For your quote to be of the highest accuracy, please complete all fields.

* Name		* E-mail
* Street		* City
* State		* Zip
County
* Home Phone		Work Phone
Fax Phone
Web Site

Limit of Liability Desired		If other
Deductible		If other

Type of Business
Corporation	LLC	Partnership	Sole Proprietorship

1. Is the firm owned by, associated with, or controlled by any other business? (check if yes)

If yes, please give details:

2. Describe in detail the nature of the professional or business activities for which insurance is desired:

3. Describe the types of claims you intend to have insured by this policy:

4. How many years have you been engaged in your current occupation / business?

5. Are you engaged in any other profession or business? (check if yes)

If yes, please give details:

6. Staff Information

Number of Partners / Officers
Professional / Technical Personnel
Clerical

Partners / Principals / Key Employees
Name in full	Professional Qualifications	Date Qualified	How long in practice?	How long as Partner / Principal?
1
2
3
4

Independent Contractors

Do you hire independent contractors? (check if yes)
If so Do you require them to carry their own professional liability insurance?	Yes No
Do you wish to have them covered as an insured by this policy?	Yes No
Describe services that Independent Contractors provide to you:

Please give details of membership in any professional / trade organization:

Estimated gross income for the current year:
Gross income past 3 years:
Year
Gross Income

Are any changes in the nature or size of your business
anticipated over the next 24 months? If so, please provide details.

Work Done

Complete information of your three largest projects in the last year.
Name	Services	Revenue

Do you have a written contract with each client?
If not, explain in the notes at the end how you define your relationship to your clients.
Does an attorney review such contracts prior to use?
Do you hold harmless clauses?
If yes, do you benefit from these contractual clauses or language?
Do you have a procedure requiring the review or follow-up of complaints?
Do you have a formalized training program for newly-hired employees?
Does any one client represent 25% or more of your annual income? If yes, explain in detail at the bottom of this form.
Are your fees contingent upon cost reduction?
Do you furnish any written guarantees / warranties to any client? If yes, please provide details at the bottom of the form.

Have you, or any of the firm's predecessors in business, or any partners, directors, officers, or employees been investigated or cited by any regulatory agency for violations arising out of their activities?

If so, give full details

Are you or any of your firm's partners, directors, or officers aware of any circumstances which might give rise to a claim being made against the applicant or its past or present partners, directors, or officers?

If so, give full particulars:

Have any claims ever been made against the firm or any of its past or present partners, directors, or officers?

If so, give full particulars:

Has any application for insurance made by you or your predecessors
in business ever been declined, cancelled, or renewal refused?

If so, give full particulars:

Has any principal / employee ever had their license revoked / suspended?

Please provide the following information for E & O insurance, if any, carried during the last three years:

Policy Period
Insurer
Limit
Deductible
Premium
Claims Made or Occurrences

Please provide the following information for General Liability Coverage currently in force:

Policy Period
Insurer
Limit
Deductible
Premium
Claims Made or Occurrences

Notes

* Where did you hear about our site?

OTHER:
(if it's a link, please be specific)

Please select the most convenient method of contacting you:
phone email	fax mail

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All Rights Reserved.

102 N. Washington, P.O. Box 950, El Campo, TX 77437
800-541-9849
Tel: 979-543-2709 • Fax: 979-543-9030
txins@txins.com

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