Professional Liability Online Form Professional Liability Applicant's Name Business Name Phone# E-mail Address Address Address Description of Primary Operations # Employees Payroll Provide Dollar Amount Gross Sales Provide Dollar Amount Describe all professional services performed for others and indicate the percentage of gross revenues derived from each activity Include Percentage Services ctd. * Include Percentage Services ctd. Include Percentage Services ctd. Include Percentage Are alternative facilities available in the event of a shutdown/failure of the Applicant’s network? Yes No Does the Applicant have written procedures for routine backups and maintain proof of backups? Yes No Is the Applicant or any principal, partner, owner, officer, director, employee, manager or managing member of the Applicant or any person(s) or organization(s) proposed for this insurance aware of any fact, circumstance, situation, incident or allegation of negligence or wrongdoing, which might afford grounds for any claim such as would fall under the proposed insurance? Yes No During the last five years, have there been any claims or proceedings arising out of professional services against the Applicant, or any of its principals, partners, owners, officers, directors, employees, managers, managing members, its predecessors, subsidiaries, affiliates, and/or against any other person or organization proposed for this insurance? Yes No Current Dec Page/Loss Run Report Submit If you are human, leave this field blank.