Errors and Omissions Insurance Form
Complete and submit your application for E&O insurance online.
Mandatory Fields are marked with an asterisk *. (If a manadatory field does not apply to you enter "na".)
1.
2.
3.
4.
Provide a clear and detailed description of the Professional activities that you undertake.
5.
Fees
State the Professional services performed or expected to be performed by the applicant
indicating the approximate percentage of total fees derived from each category.
What type of work is sub-contracted?
What percentage of the applicant's fees will be earned:
For work outside of Canada, please provide details with respect to the location,
type of work and fees for each project.
6.
Total Number of:
7.
8.
Explain fully the educational requirements of your profession.
9.
10.
11.
12.
13.
Please list your five largest projects done during the past five years.
14.
15.
If Yes, please to the question above please provide the following:
If No, please state reason:
16. a)
16. b)
IF THE ANSWER TO EITHER 16 a) or 16 b) IS YES, COMPLETE THE CLAIMS HISTORY SECTION AT THE END OF THIS FORM
NOTE: THE POLICY DOES NOT COVER ANY CLAIM OR CIRCUMSTANCE STATED IN 16 a) or 16 b) OR ANY ACT, ERROR, OMISSION OR CIRCUMSTANCE WHICH COULD GIVE RISE TO A CLAIM, OF WHICH THE APPLICANT HAS KNOWLEDGE PRIOR TO THE INCEPTION OF THE POLICY.
17.
18.
19.
Limits
20.
We hereby declare that the above statements and particulars are true and that we
have not suppressed or misstated any material facts and we agree that this declaration
shall be the basis of any binder or contract or insurance with the Insurer, and
that the limits and deductibles as stated in the said binder or contract of insurance
shall govern.
It is understood and agreed that the completion of this application does not bind
the Insurer to the issue of the insurance nor the Applicant to the purchase of the
insurance.
It is further understood and agreed that if, following submission of this application
to the Insurer and prior to the date requested for coverage to be effective, the
Applicant becomes aware of any information which has a bearing on question 16 a)
or 16 b) of this application, the Insurer shall be immediately notified in writing
of such information.
CLAIMS HISTORY SECTION (This section is required if either of question 16 a) or 16 b) was "Yes"
CLAIM # 1
Please provide a description of the above Claim
CLAIM # 2
Please provide a description of the above Claim
CLAIM # 3
Please provide a description of the above Claim