CPLIC, RRG Application for Coverage

Section One - Contact Information

Named Insured is a:*

Named Insured (Including DBA)*

Address Line 1*

City*

State / Province*

ZIP / Postal Code*

Primary Contact First Name*

Primary Contact Last Name*

Primary Contact Phone*

Primary Contact Email*

Do you have a secondary or billing contact you would like to add?*

Yes

Secondary/Billing Contact Name

Secondary/Billing Phone Number

Secondary/Billing Contact Email

Would you like to enable online access for the secondary contact?

Yes

Website

Date Established:*

Date Coming Under Current Ownership*

Years of Claim Experience:*

Does the named insured operate under any other business entity names or from any additional branch office?*

Yes

Name

Address

Name

Address

Name

Address

If you need to submit additional business entity names or branch locations, please email their information to memberservices@cplic.net

How did you hear about us?*

Conference/Convention Name:*

Other (please explain)*

Employer/Organization Name:*

Name of Current/Former Insured*

___________________________

Section Two - Coverages

Effective Date*

Limit Of Liability *the most common limits requested are $1,000,000/$1,000,000**

The limits that you have selected will require additional information and/or documentation in order to provide a quote. A representative will be in touch after your application has been submitted to review any additional requirements.

Deductible *the most common deductible requested is $1,000**

Do you have current insurance?*

Yes

Retroactive Date:*

Please upload a copy of your current insurance.*

Please upload a copy of your resume.*

What was your gross revenue for the 12 months prior to the requested effective date?*

What is your projected gross revenue for the 12 months after the requested effective date?*

___________________________

Section Three - Professional Services

Please select which states your business earns revenue:*

Please indicate the percentage of revenue earned in each state you have selected.

**NOTE TOTAL PERCENTAGE OF REVENUE MUST EQUAL 100%**

Alabama:*

Alaska Revenue*

Arizona:*

Arkansas:*

California:*

Colorado:*

Connecticut:*

Delaware:*

District of Columbia:*

Florida:*

Georgia:*

Hawaii:*

Idaho:*

Illinois:*

Indiana:*

Iowa:

Kansas:

Kentucky:

Louisiana:

Maine:

Maryland:

Massachusetts:

Michigan:

Minnesota:

Mississippi:

Missouri:

Montana:

Nebraska

Nevada:

New Hampshire:

New Jersey:

New Mexico:

New York:

North Carolina:

North Dakota

Ohio:

Oklahoma

Oregon:

Pennsylvania:

Rhode Island:

South Carolina

South Dakota:

Tennessee:

Texas:

Utah:

Vermont:

Virginia:

Washington:

West Virginia:

Wisconsin:

Wyoming

Do you provide Third Party Administration (TPA) Services? Third party administration services involve performing administrative and operational for an insurance carrier pursuant to a written contract.*

Yes

What percentage of your revenue is from TPA work?*

Please indicate the number of each type of personnel:

Number of Employees (W2):

Number of Non-Employees (1099/Independent Contractor:

What is the approximate percentage of gross revenue attributed in whole or in part to non-employee personnel?*

Describe your supervision policies for work performed by non-employee personnel:*

Number of Owners:

List any professional organizations where you or your employees are members:

Please list the 3 largest clients (based on gross annual revenue) of the Named Insured and provide the associated details:

Client Name*

Services Provided*

Contract?*

Yes

Gross Annual Revenue:*

Client Name (if no additional clients please put NA)*

Services Provided*

Contract?

Yes

Gross Annual Revenue:

Client Name

Services Provided

Contract?

Yes

Gross Annual Revenue:

Does the named insured or any personnel provide professional services other than claims services, including but not limited to agency or brokerage services?*

Yes

Please describe other services in detail:*

CPLIC, RRG does not provide coverage for professional services other than claims services or agency/brokerage services necessary to support the Named Insured's professional claims service operations and clients.

Please indicate the areas you earn revenue and total percentage of revenue for each:

**PERCENTAGES MUST EQUAL 100%**

Property (Includes Flood and Catastrophe):

Liability:

Workers Compensation:

Appraisal/Umpire:

Other:

Please describe:*

Are all employee or non-employee professionals and management personnel licensed by the state(s) in which they provide claims services, if licenses are required?*

Yes

Not Required

Does the Named Insured or its personnel provide professional services as a public adjuster?*

Yes

What percentage of revenue is from Public Adjusting Services?*

PLEASE BE AWARE PUBLIC ADJUSTING SERVICES MAY NOT BE COVERED UNDER THIS POLICY.

___________________________

Section Four - Prior Activities and Claims History

For the period of five (5) years prior to the proposed effective date of CPLIC coverage, has the Named Insured, any of its operating locations, including businesses acquired, or any personnel:

Had any license denied, suspended, or revoked?*

Yes

Been investigated, disciplined, sued or fined by any regulatory agency?*

Yes

Had a policy or application for Professional or General Liability non-renewed, declined, or cancelled?*

Yes

Had any claims, lawsuits or other actions made against them?*

Yes

Is the named insured or any of its employee or non-employee personnel aware of :*

any actual or alleged facts, circumstances, situation, action, error or omission which may be reasonably expected to result in a claim, lawsuit or other action to be taken against the Named Insured, any of its operating locations or employee or non-employee personnel?

Yes

Please upload explanatory documentation for any of the items that were answered "Yes" in the prior questions.*

___________________________

Section Five - Polling of Personnel

I have on this date taken a polling of all of my past and present employees, adjusters, claims representative, supervisors, and managers, and I am not aware of any verbal or written demands for money or services; or facts or circumstances that could generate a demand for money or services against any of our current or former adjusters, claims representatives, supervisors, and managers, or any of our clients related to our provision of professional services

Please indicate your response to the above question:*

Yes

___________________________

Section Six - Drone/UAV Endorsement

Would you like a quote for the Drone/UAV endorsement?*

Please be aware a valid UAV/Pilot certificate is required for this endorsement.

Yes

Will the Unmanned Aerial Vehicle ("UAV") be operated within all applicable regulations at all times?*

Yes

Estimated Total Annual Flight hours for Named Insured*

Please list the Manufacturer and Model of each drone that will be used in your business:*

UAV Operator Name*

Date Remote Pilot Cert. Obtained:*

Are there additional operators who will be operating an unmanned aerial vehicle on behalf of the named insured?*

Yes

Additional Operator Name*

Date Remote Pilot Cert. Obtained:*

Has this additional operator accrued 50 Flight Hours?*

Yes

Additional Operator Name

Date Remote Pilot Cert. Obtained:

Has this additional operator accrued 50 Flight Hours?

Yes

Within the last 3 years, have any operators listed above:

been cited for violation of FAA regulations?*

Yes

had any claims, lawsuits, or other actions made against them involving UAV operations?*

Yes

Please attach explanatory documentation for the items that were answered "yes"*

Please attached a copy of the remote pilot certificate for each operator listed.*

___________________________

Section Seven - Cyber Liability and EPLI

Our strategic partnerships now allow us to offer our members cyber liability coverage with limits of up to $3 million.

This coverage helps protect your business from interruptions or losses caused by factors such as:

Ransomware
Actual or Suspected Security Breaches
Phishing Schemes
Social Engineering
Your Liability in cases where you are responsible for a security breach of a client's system.

Through our affiliation with A++ rated carriers, we are able to offer affordable EPLI coverage to protect you from claims like

Discrimination
Harassment
Retaliation
Inappropriate Workplace Conduct
Disability Access Discrimination
Third Party Discrimination
Third Party Harassment

Thank you for your interest in additional coverages. Our underwriting team will provide you with additional information for applying for your selected additional coverages following a review of your application for E&O coverage.

Please do not navigate away from this page while application is processing. You will be directed to the CPLIC, RRG homepage upon successful submission of your application.

Signature Block

Please Review and Sign

Signature Block

Read the following closely before completing the e-signature.

Named Insured:

I, the undersigned, being fully authorized and permitted by the Named Insured to execute this application for coverage, understand that the coverage applied for applies only on a Claims Made basis and only for claims which are first made against the Named Insured and reported to CPLIC during the policy period. I understand that coverage ceases upon termination of the policy, subject to modification by availability and payment of premium for extended reporting period coverage.

By signing this application for coverage, I, on behalf of the Named Insured and all of its operating locations, subsidiaries, and employee and non-employee personnel, represent and warrant that this application and all attachments, amendments and documentation are complete, accurate, representative of the full scope and depth of my knowledge and that the representations made herein are made with my full knowledge and consent that I have conducted sufficient internal investigation to have a reasonable belief that all answers and representations are full, complete and accurate. I agree that, after completion of this application, I will send written notice of any changes, modifications or other material instances which occur or come to my attention prior to the issuance of the CPLIC policy should the application be accepted by CPLIC. CPLIC reserves the right to modify or withdraw from any offers of coverage based upon information provided by the Named Insured or discovered through any other source in its underwriting review of this application or any time thereafter.

As a condition precedent to the issuance of this policy and the applicability of Coverage provided for herein, the applicant agrees that there shall be no cause of action against the Company. The applicant has the authority to and hereby knowingly and intentionally waive any and all right to sue the Company. The applicant has the authority to and hereby knowingly and intentionally waives any and all right to assign actual or potential Coverage available under this policy to any other person or organization.

I further warrant that I have reported in writing all claims, notices, or demands to the current insurer. Any demands for money or services, facts or circumstances that we are aware of have already been reported in writing to Claim Professionals Liability Insurance Company during the application process. I understand the policy will not provide any coverage for these claims or events under any circumstances.

By accepting the policy applied for the applicant agrees to submit any claim of dispute, controversy or disagreement over the Coverage available under this policy, any claim for actual or alleged breach of duty arising out of this policy, or any other dispute or claim of any kind between the Company and any Insured to binding arbitration in accordance with the policy. In the event of such a dispute, both the Company and the applicant agree that if a policy is issued, binding arbitration is the sole and exclusive remedy to resolve any dispute between the Company and the applicant.

Signing this application and declaration does not bind the applicant to purchase the insurance. It is agreed that this application and declaration shall constitute a warranty should a policy be issued. By signing this application the applicant acknowledges that he/she/it is aware that if at any time it is discovered that any of the statements of fact contained in the application are false the policy may be declared void from its inception at the sole option of the Company.

I have read all of the preceding application for a CPLIC policy and agree that to the best of my knowledge and belief it represents a true and complete statement. The policy wording for the CPLIC policy has been made available to me prior to signing this application and which I understand contains different terms, conditions and limitations than previous editions of the CPLIC policy, or similar policies issued by other insurers. This application is submitted to the CPLIC with the knowledge that it will be used as the factual basis for the decision of the CPLIC to insure or not insure the applicant for whom I am authorized to sign.

Coverage provided by CPLIC is conditioned upon underwriting review and acceptability of the Named Insured as a member of Claim Professionals Liability Insurance Company, Risk Retention Group, and is subject to the RRG membership and capital requirements. This application will be part of your policy if issued.

Applicant agrees to provide risk management information, if requested, at a later date which the Board determines is good for the group.

Applicant agrees that if insured with CPLIC, CPLIC may release that he is insured with CPLIC to such organizations or prospects as CPLIC deems appropriate.

I read and understand the English language and understand every statement made in this application. If I cannot read
the application I, and the person who signs beside my name has read the application to me and attests that the statements made in the application were read to me in a language in which I am fluent and that I sign this application knowingly and in good faith.

Initial Application

Signature Block