Errors and Omissions Insurance

Professional Liability Insurance Quick Quote Form

Please complete this form for a no obligation free premium indication for Consultant's Professional Liability Insurance.

All indications will be given by phone, by e-mail or fax as soon as possible excluding weekends. Available for firms domiciled in the United States.

Completion of every section is required to provide you an accurate quotation. NOTE: If you are an insurance agent or broker please enter your client's information in the boxes below. Provide your agency contact information in the boxes at the bottom of this form.

Are you:*
Name of Firm:*
Salutation:*
First Name:*
Last Name:*
Principal Business Address:*

City:*
State:*
Zip:*
Email:*
Web Site (if any):
Daytime Telephone:	ext.
Facsimile:	ext.
How would you like to be contacted:
Number of Professional Consultants and Technicians:
Number of Support Staff:

Desired Limit of Liability: (you may choose more than one)
$500,000	$1,000,000
Other:

Deductible (you may choose more than one):
$2,500	$10,000
$5,000	Other:

Do you use Independent Subcontractors?
Yes	No

What type of consulting do you specialize in (e.g. Healthcare, Marketing)?

Please indicate by percentage of annual receipts, consulting services in the following areas (no actual revenue figures required at this stage):
Economic:	%	Roofing:	%
Organizational Structure:	%	Legal Nurse:	%
Employee Evaluation:	%	Expert Witness Testimony:	%
Systems Analysis:	%	Benefit Consulting:	%
Long Range Planning:	%	IT Consulting:	%
Product Development:	%	Merger and Acquisition:	%
Wrongful Death/Pers. Injury:	%	Marketing:	%
Compliance:	%	Other 1:	%
Technology:	%	Other 2:	%
			100%

Gross Annual Receipts:

Current Professional Liability (E&O) Insurance Company:

Current Policy Expiration Date (if any):

Current Prior Acts Date:

Current Limit and Deductible:

Current Annual Premium:

How did you hear about our services?

Mail
I saw your ad in:
Other, please explain:
Messages:

This quick quote form has been designed to provide you with a premium indication. Should you decide to apply for coverage, more underwriting information will be required. Quotations are absolutely free and without obligation.

Thank you. You have our assurance that your name will not be lent or sold to any third party.