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Asia Insurance Business Professional Liability Quote

Customer Information
Business Name
First Name	Middle Initial	Last Name
Street #	Street Name	Apt or Unit
City	State	Zip	-
Home Phone	Work Phone	Email

Please describe in detail all Professional Services that your business provides that you would like to have covered under this policy. Note: Coverage will only be provided for those services listed on the policy as Professional Services.
What are the total gross receipts/revenues, by state, derived from the Professional Services described in number 1 above?
Does your firm conduct qualification inquiries on all potential hires?
Does your firm conduct qualification inquiries on all potential hires?			Yes No
Total number of professional employees (employees providing professional services as described in number 1 above) employed by the applicant in the last 12 months (all locations).
Year		Number of Employees
Total Number of professional employees that were terminated by the applicant and the total number of employees that voluntarily left their employment in the last 12 months (all locations).
Year		Terminated		Voluntarily Left
Have any Professional Liability claims been made against you within the past 3 years?				Yes No
Date	Description			Total Amount of Loss


Is the applicant aware of any facts, incidents or circumstances which may result in any Professional Liability losses, claims or suits being made against them?			Yes No
If yes, please provide details
Desired Limits: (Each Wrongful Act / Aggregate) (other limits may be available upon request)
$100,000/$100,000		$250,000/$250,000		$500,000/$500,000
$750,000/$750,000		$1,000,000/$1,000,000		$2,000,000/$2,000,000
Desired Deductible: (Each Wrongful Act)
$500	$1,000	$2,500	$5,000	$7,500	$10,000
$15,000	$20,000	$25,000
Is your business currently covered by a Professional Liability policy?			Yes No

Please use the space below to add comments regarding any special circumstances or coverage needs

Disclosure

Where permitted by law, the insurance companies we quote will individually confirm your information through consumer reports, which may include credit reports. Each company will provide the source of the report if you are interested. Your information may be shared with the quoting company's affiliated underwriting companies, independent representatives or other insurance partners.

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