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Applicant Information

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General Liability Supplemental

Association Information

Personnel - Number of Staff

Last Year (Numbers only, no commas) This Year (Numbers only, no commas)
# Principals / Partners / Directors
# Other Licensed Professionals
# Other Staff

Gross Billing - Total Gross Billings for professional services (collected or not) to include reimbursable expenses and sub-consulting fees

Numbers only. No special characters including $, commas or spaces. Periods are accepted.

$
$
$

Gross Billing cont.

(Numbers only, no commas)
Work pursuant to Federal or State grants
%
Feasibility Studies
%
Patent Research
%
All Other Billings
%
Total (Must equal 100%) 0%

Gross Billing cont.

%

Professional Disciplines

Specify as a percentage of the Applicant's Gross Billings (Total must equal 100%, Numbers only):

Description Percentage Years Experience
Aerospace / Transportation
%
Metals / Metal Products
%
Agriculture & Food
%
Nuclear
%
Analytical
%
Organic
%
Biochemistry
%
Paint / Coatings
%
Biotechnology
%
Patent Research
%
Chemical Education
%
Personal Care / Cosmetics
%
Chemical Information
%
Pharmaceutical / Medicinal
%
Clinical / Diagnostic
%
Physical
%
Colloids & Surfaces
%
Pollution - Analysis
%
Combination Chemistry
%
Pollution - Remediation
%
Computing / Molecular Modeling
%
Polymer / Plastics
%
Electronics / Semiconductors
%
Process Engineering / Modeling
%
Description Percentage Years Experience
Energy / Fuels
%
Pulp / Paper / Wood
%
Environmental - Analyzing
%
Rubber
%
Environmental - Remediation
%
Soaps / Detergents / Cleaners - Process
%
Expert Witness
%
Soaps / Detergents / Cleaners - Analysis
%
Forensics
%
Soaps / Detergents / Cleaners - Research
%
Geochemistry
%
Textiles / Fiber
%
Glass / Ceramics / Composites
%
Toxicology
%
Health & Safety
%
Writing - Technical
%
Inorganic Chemistry
%
Writing - Reporting
%
Lubricants / Oils (Petrol)
%
Marketing / Sales / Business
%
Materials
%
%
Total (Must equal 100%):  0%

Professional Disciplines cont.

Please describe the applicant’s largest projects during the past 3 years.

Client 1

$
$

Client 2

$
$

Client 3

$
$

Client 4

$
$

Subcontractors / Subconsultants

%

Management

Loss History

Insurance

Previous insurance details:

$
$
$

Please check coverage limits and deductible requested:

Cover Limits of Liability

$

Deductible

$

Laboratory Questionnaire

%

Patent Research Consulting Questionnaire

Provide a percentage breakdown of Patent Services in the following categories (must have a 100% Total, Numbers only):

Patent Infringement Counseling
%
Domestic Patent Prosecution
%
Foreign Patent Presecution
%
Patent Searches
%
Patent Applications Filings
%
Others
%
Total (Must equal 100%) 0%

If Yes, outsource entities are selected by:*

If Yes, provide percentage breakdown by:*

%
Infringement*
%
Validity*
%
Total (Must equal 100%) 0%

Are the following requested from the client, on or during provision of Patent Research Consulting services:*

Is the following advice provided to the client, on or during provision of Patent Research Consulting services:*

Process Engineering Supplemental

What other industries do you provide Process Engineering services to (e.g. pharmaceuticals):

Industry Type Gross Revenue # Years Exp

Please list the 3 largest projects (by gross dollar value) involving Process Engineering services in the past year:*

Client Gross Revenue
%

Biotech Supplemental

Operations & Services

Indicate the uses or operations to which the insured's operations or services apply*:

Policy Questions

Which of the following are part of the insured's operations? (select all that apply)*

Which Biosafety Level rating are the insured's operations?*

Does the insured work with any of the following? (Select all that apply)*

Biotech Human Clinical Trial

Please indicate what type of Human clinical Trial: (Select all that apply)*

Biotech cont.

Please indicate which of the following the insured uses: (Select all that apply)*

Which of the following Quality Registrations does the insured have? (Select all that apply)*

Which of the following apply to the insured's facilities? (Select all that apply)*

Please provide the details for your current coverage:

$

If greater than 5 gallons, How are the chemicals/flammables stored when not in use? (Select all that apply)*

Applicant Cyber Activities

%

%

Does the Applicant use the following controls:

Cyber Liability Supplemental

Introduction

Information Security & Privacy Controls

Does the Applicant use the following controls:

What format does the Applicant utilize for backing up and storage of computer system data?

Website Content Controls

Please check all descriptions of website content posted by the Applicant, including content posted to social media web pages:

Prior Claims and Circumstances

During the past 5 years has the Applicant:

Submission

THE APPLICANT DECLARES THAT, AFTER INQUIRY, TO THE BEST KNOWLEDGE OF ALL PERSONS TO BE INSURED THE STATEMENTS SET FORTH HEREIN AND IN ANY ATTACHMENTS MADE HERETO ARE TRUE, AND NO MATERIAL FACTS HAVE BEEN SUPRESSED, OMITTED, OR MISSTATED.

UNDERWRITERS RESERVE THE RIGHT TO AMEND THE TERMS, CONDITIONS AND LIMITATIONS OF ANY POLICY ISSUED AS A RESULT OF THIS APPLICATION, IF SUBSEQUENT TO THE DATE OF THIS APPLICATION, BUT PRIOR TO THE INCEPTION OF SUCH POLICY, THERE ARE ANY MATERIAL ALTERATIONS TO THE INFORMATION CONTAINED HEREIN.

COMPLETION OF THIS APPLICATION DOES NOT BIND THE UNDERWRITER TO PROVIDE COVERAGE, BUT IT IS AGREED THAT THE STATEMENTS AND PARTICULARS CONTAINED HEREIN WILL BE RELIED UPON BY UNDERWRITERS IN THE EVENT A POLICY IS ISSUED. THIS APPLICATION IS SIGNED ON BEHALF OF ALL OWNERS, PRINCIPALS, PARTNERS, SHAREHOLDERS, DIRECTORS AND EMPLOYEES.

BY SUBMITTING THIS APPLICATION, THE APPLICANT AGREES THAT IN THE EVENT THE APPLICATION CONTAINS MISREPRESENTATIONS OR FAILS TO STATE FACTS MATERIALLY AFFECTING THE RISK ASSUMED BY THE INSURING COMPANY UNDER A POLICY ISSUED, THE POLICY MAY BE DEEMED NULL AND VOID. APPLICATION WILL ATTACH TO AND FORM PART OF THE POLICY.

GL SUPPLEMENTAL DISCLAIMER

ALL WRITTEN STATEMENTS AND MATERIALS FURNISHED IN CONJUNCTION WITH THIS SUPPLEMENTAL APPLICATION ARE HEREBY INCORPORATED BY REFERENCE INTO THIS APPLICATION AND MADE A PART HEREOF.

THIS SUPPLEMENTAL APPLICATION DOES NOT BIND THE APPLICANT TO BUY, OR THE UNDERWRITERS TO ISSUE, THE INSURANCE, BUT IS AGREED THAT THIS APPLICATION SHALL BE THE BASIS OF THE CONTRACT SHOULD A POLICY BE ISSUED, AND IT WILL BE ATTACHED TO AND MADE A PART OF THE POLICY.

THE APPLICANT FURTHER DECLARES THAT IF THE INFORMATION SUPPLIED ON THIS SUPPLEMENTAL APPLICATION CHANGES BETWEEN THE DATE OF THIS APPLICATION AND THE TIME WHEN THE POLICY ISSUED, THE APPLICANT WILL IMMEDIATELY NOTIFY THE COMPANY OF SUCH CHANGES, AND THE UNDERWRITERS MAY WITHDRAW OR MODIFY ANY OUTSTANDING QUOTATIONS AND/OR AUTHORISATION OR AGREEMENT TO BIND THE INSURANCE.

I HAVE READ THE FOREGOING SUPPLEMENTAL APPLICATION OF INSURANCE AND WARRANT THAT THE RESPONSES PROVIDED ON BEHALF OF THE APPLICANT ARE TRUE AND CORRECT.

CYBER SUPPLEMENTAL DISCLAIMER

THE UNDERSIGNED IS AUTHORIZED BY THE APPLICANT TO SIGN THIS APPLICATION ON THE APPLICANT’S BEHALF AND DECLARES THAT THE STATEMENTS SET FORTH HEREIN AND ALL WRITTEN STATEMENTS AND MATERIALS FURNISHED TO THE INSURER IN CONJUNCTION WITH THIS APPLICATION ARE TRUE. SIGNING OF THIS APPLICATION DOES NOT BIND THE APPLICANT OR THE INSURER TO COMPLETE THE INSURANCE, BUT IT IS AGREED THAT THE STATEMENTS CONTAINED IN THIS APPLICATION, ANY SUPPLEMENTAL APPLICATIONS, AND THE MATERIALS SUBMITTED HEREWITH ARE THE BASIS OF THE CONTRACT SHOULD A POLICY BE ISSUED AND HAVE BEEN RELIED UPON BY THE INSURER IN ISSUING ANY POLICY.

THIS APPLICATION AND MATERIALS SUBMITTED WITH IT SHALL BE RETAINED ON FILE WITH THE INSURER AND SHALL BE DEEMED ATTACHED TO AND BECOME PART OF THE POLICY IF ISSUED. THE INSURER IS AUTHORIZED TO MAKE ANY INVESTIGATION AND INQUIRY IN CONNECTION WITH THIS APPLICATION AS IT DEEMS NECESSARY.

THE APPLICANT AGREES THAT IF THE INFORMATION SUPPLIED ON THIS APPLICATION CHANGES BETWEEN THE DATE OF THIS APPLICATION AND THE EFFECTIVE DATE OF THE INSURANCE, THE APPLICANT WILL, IN ORDER FOR THE INFORMATION TO BE ACCURATE ON THE EFFECTIVE DATE OF THE INSURANCE, IMMEDIATELY NOTIFY THE INSURER OF SUCH CHANGES, AND THE INSURER MAY WITHDRAW OR MODIFY ANY OUTSTANDING QUOTATIONS OR AUTHORIZATIONS OR AGREEMENTS TO BIND THE INSURANCE.

I HAVE READ THE FOREGOING APPLICATION FOR INSURANCE AND REPRESENT THAT THE RESPONSES PROVIDED ON BEHALF OF THE APPLICANT ARE TRUE AND CORRECT.

FRAUD WARNING DISCLOSURE

ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT (S)HE IS FACILITATING A FRAUD AGAINST THE INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT MAY BE GUILTY OF INSURANCE FRAUD.

NOTICE TO ALABAMA, ARKANSAS, LOUISIANA, NEW MEXICO AND RHODE ISLAND APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.

NOTICE TO COLORADO APPLICANTS: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES, DENIAL OF INSURANCE, AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AGENCIES.

NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT.

NOTICE TO FLORIDA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY IN THE THIRD DEGREE.

NOTICE TO KANSAS APPLICANTS: ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE PRESENTED OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER OR AGENT THEREOF, ANY WRITTEN STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY FOR PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY FOR COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT.

NOTICE TO KENTUCKY, NEW JERSEY, NEW YORK, OHIO AND PENNSYLVANIA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIMS 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, AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. (IN NEW YORK, THE CIVIL PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS ($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.)

NOTICE TO MAINE, TENNESSEE, VIRGINIA AND WASHINGTON APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES OR A DENIAL OF INSURANCE BENEFITS.

NOTICE TO MARYLAND APPLICANTS: ANY PERSON WHO KNOWINGLY OR WILLFULLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY OR WILLFULLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.

NOTICE TO OKLAHOMA APPLICANTS: WARNING: ANY PERSON WHO KNOWINGLY, AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY.

THE UNDERSIGNED AUTHORIZED EMPLOYEE OF THE APPLICANT DECLARES THAT THE STATEMENTS SET FORTH HEREIN ARE TRUE. THE UNDERSIGNED AUTHORIZED EMPLOYEE AGREES THAT IF THE INFORMATION SUPPLIED ON THIS APPLICATION CHANGES BETWEEN THE DATE OF THIS APPLICATION AND THE EFFECTIVE DATE OF THE INSURANCE, HE/SHE WILL, IN ORDER FOR THE INFORMATION TO BE ACCURATE ON THE EFFECTIVE DATE OF THE INSURANCE, IMMEDIATELY NOTIFY THE UNDERWRITER OF SUCH CHANGES, AND THE UNDERWRITER MAY WITHDRAW OR MODIFY ANY OUTSTANDING QUOTATIONS OR AUTHORIZATIONS OR AGREEMENTS TO BIND THE INSURANCE. FOR NEW HAMPSHIRE APPLICANTS, THE FOREGOING STATEMENT IS LIMITED TO THE BEST OF THE UNDERSIGNED’S KNOWLEDGE, AFTER REASONABLE INQUIRY. IN MAINE, THE UNDERWRITERS MAY MODIFY BUT MAY NOT WITHDRAW ANY OUTSTANDING QUOTATIONS OR AUTHORIZATIONS OR AGREEMENTS TO BIND THE INSURANCE.

NOTHING CONTAINED HEREIN OR INCORPORATED HEREIN BY REFERENCE SHALL CONSTITUTE NOTICE OF A CLAIM OR POTENTIAL CLAIM SO AS TO TRIGGER COVERAGE UNDER ANY CONTRACT OF INSURANCE. NO COVERAGE SHALL BE AFFORDED FOR ANY CLAIMS ARISING OUT OF A CIRCUMSTANCE NOT DISCLOSED IN THIS APPLICATION.

SIGNING OF THIS APPLICATION DOES NOT BIND THE APPLICANT OR THE UNDERWRITER TO COMPLETE THE INSURANCE, BUT IT IS AGREED THAT THIS APPLICATION SHALL BE THE BASIS OF THE CONTRACT SHOULD A POLICY BE ISSUED, AND IT WILL BECOME PART OF THE POLICY.

ALL WRITTEN STATEMENTS AND MATERIALS FURNISHED TO THE INSURER IN CONJUNCTION WITH THIS APPLICATION ARE HEREBY INCORPORATED BY REFERENCE INTO THIS APPLICATION AND MADE A PART HEREOF. FOR NORTH CAROLINA, UTAH, AND WISCONSIN APPLICANTS, SUCH APPLICATION MATERIALS ARE PART OF THE POLICY, IF ISSUED, ONLY IF ATTACHED AT ISSUANCE.

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