This completed document should be submitted to:
Old Republic Professional Liability, Inc.
191 North Wacker Drive, Suite 1000
Chicago, IL 60606-1905
T: 312.750.8800	www.oldrepublicpro.com

APPLICATION FOR 
EXCESS PROFESSIONAL LIABILITY INSURANCE

THIS IS AN APPLICATION FOR AN EXCESS POLICY PROVIDING COVERAGE ON A CLAIMS MADE AND REPORTED BASIS, WITH DEFENSE COSTS INCLUDED IN THE LIMIT OF LIABILITY

Instructions

•	All questions on this application must be answered. If additional space is required to complete an answer, continue on a separate addendum.
•	All responses must be typed or printed clearly in ink. 
•	A complete copy of the primary insurer’s application must be submitted with this application, unless previously furnished.
•	This application must be completed, signed and dated by a partner or senior officer of the applicant.

1. 	Applicant

Name of applicant:       
Street address:       

City:       					State:        				Zip code:        

Designated contact person:      				  Title:        

* include all entities shown in the primary insurer’s application

2.	Underlying Insurance

List the primary and intermediate layers of insurance which will be underlying to the proposed excess insurance:	

Primary Insurance:
     			 	Expiration
	Name of Insurer		Limit of Liability		Deductible		Premium		(Mo/Day/Yr)

	     			     			     				     			     

Intermediate Insurance (by layer):
           		 	Expiration
	Name of Insurer		Limit of Liability					Premium                 (Mo/Day/Yr)         

		     			     	xs		     				     			     		

		     			     	xs		     				     			     		

		     			     	xs		     				     			     		

Complete copies of the underlying policies must be furnished to Old Republic Professional Liability, Inc. with this application or as soon as they become available. 

3.	Claims Information

During the past 5 years has any claim been made against the applicant or any predecessor firm or any current or former partners, directors, officers or employees of the applicant or any predecessor firm? (  ) Yes (  ) No. If yes, provide the following information for each claim on a separate addendum:

a.	the full name of the claimant;
b.	the actual date of claim (month/day/year);
c.	a description of the alleged acts, errors or omissions giving rise to the claim;
d.	the total damages or other relief sought by the claimant;
e.	name of the insurer responding to the claim and the date it was reported;
f.	total amounts paid in settlement or in satisfaction of any judgment, inclusive of the deductible;
g.	total expenses incurred to defend the claim, inclusive of the deductible; and
h.	current status of the claim (if open, include most recent developments).

The applicant may submit claim supplements completed for the primary insurance in response to question 3, provided these supplements contain the information required in a through h above. Please do not submit suit papers or other legal documents.

4.	Knowledge

Does the applicant, after inquiry of all partners, directors, officers or employees, know of any facts or circumstances that could reasonably give rise to a claim against the applicant or any predecessor firm or any current or former partners, directors, officers or employees of the applicant or any predecessor firm? 
( ) Yes ( ) No. If yes, provide full details on a separate addendum. 

No coverage will be provided under the proposed excess policy for any claim arising out of the facts or circumstances disclosed or required to be disclosed in response to question 4. To avoid loss of coverage, you should report all known facts or circumstances that may reasonably give rise to a claim to your present insurer within the time period specified in your current policy.

5.	Declaration and Signature

Completion of this application does not commit the applicant to purchase the excess insurance nor does review of this application require Old Republic Professional Liability, Inc. to issue a policy on behalf of the Old Republic Insurance Company. Should an excess policy be issued, however, this application will be the basis of the excess policy and attached to and made a part of the excess policy. All materials furnished in connection with this application, including the primary insurer’s application, are incorporated into this application by reference and deemed a part of this application.

The undersigned, acting on behalf of the applicant and all prospective insureds, represents that the statements set forth in this application and the primary insurer’s application are true, complete and accurate, and agrees that if any of the information contained in this application or the primary insurer’s application changes between the date of this application and the effective date of the proposed excess policy, he/she shall immediately notify Old Republic Professional Liability, Inc. of such changes and Old Republic Professional Liability, Inc. shall have the right to withdraw or change any outstanding insurance proposal or agreement to bind coverage on behalf of the Old Republic Insurance Company.

The undersigned understands and accepts that any excess policy issued on behalf of the Old Republic Insurance Company will provide coverage on a claims made and reported basis and that all legal fees and expenses incurred in the investigation or defense of any claim will reduce, and may completely exhaust, the limit of liability of the proposed excess policy.

Notice to residents of New York and Ohio: Any person who, knowingly and with intent to defraud any insurance company or other person, files an application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.

Fraud Warning
(All States except:  AL; AR; CO; DC; HI; KS; KY; LA; ME; MD; NJ; OH; OK; OR; PA; TN; WA)

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 civil fines and criminal penalties.
Alabama – Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof.
Arkansas – 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.

Colorado – 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.

District of Columbia – 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.

Hawaii – For your protection, Hawaii Law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.

Kansas – 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 any 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 is guilty of a crime and may be subject to civil fines and criminal penalties.
Kentucky – Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance 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.

Louisiana – 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.

Maryland – Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who 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.

New Jersey – Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

Ohio – Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against any insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud, which is a crime.

Oklahoma – 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.

Oregon – Any person who, with intent to defraud or knowingly that his is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.

Pennsylvania – Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim 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.
Maine; Tennessee; Washington – It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company.  Penalties include imprisonment, fines, and denial of insurance benefits.

						Signature: 	_____________________________________________________

Date:         					Print Name:	     

						Title:		_____________________________________________________