MPL-14001Stylist

Document Sample
MPL-14001Stylist Powered By Docstoc
					                                                                                         PROFESSIONAL STYLIST
                                                                                           ERRORS & OMISSIONS
                                                                                             INSURANCE POLICY
                                                                                          CLAIMS-MADE POLICY


                                              APPLICATION FOR
                                            PROFESSIONAL STYLIST

NOTICE: THE POLICY PROVIDES THAT THE LIMITS OF LIABILITY AVAILABLE TO PAY JUDGMENTS OR
SETTLEMENTS SHALL BE REDUCED BY AMOUNTS INCURRED FOR CLAIMS EXPENSES AND THAT CLAIMS
EXPENSES SHALL BE APPLIED AGAINST THE DEDUCTIBLE AMOUNT.

1.    Name of Applicant: _____________________________________________________________________
      Address:      _____________________________________________________________________________
      Mailing Address:       _____________________________________________________________________
      Web Site Address:      _____________________________________________________________________

2.    Date Established
                                  Mo./Day/Yr.
3.    a. Applicant is: ___ Individual ___ Partnership ___ Corporation ___ Other (specify)


4.    Professional Services

      a. Please provide a comprehensive description of the professional services performed by the Applicant. Attach a
         separate sheet if necessary
         ___________________________________________________________________________________
           ___________________________________________________________________________________
          _____________________________________________________________________________
       b. Does the Applicant provide any professional services outside the United States? ____ Yes ___ No

      c. Estimated number of clients: ________

5. Personnel

      a. Number of professional stylist: __________
      b. Number of non-professional stylist: ____________
      c. Number of independent contractors performing professional services on behalf of the Applicant:

6. Does the Applicant ever warrant or guarantee its professional services? ___ Yes ___ No



            7.      Procedures

     a. Does the applicant have a process in place to handle and resolve client complaints? ___ Yes ___ No
        If yes to any part of Question please explain:.
MPL 14001 (02/06)                                                                              Page 1 of 3
8. Prior Insurance

    a. Please provide the following information for any Errors and Omissions of Professional Liability Insurance
         the Applicant carried during the last five years:
    b.
Company                         Limit of          Deductible    Premium       Policy Period            Retro Date
                                Liability                                                              (month/day/year)




    c. Has any Errors or Omissions insurance or Professional Liability Insurance ever be declined, cancelled or
         nonrenewed? ___ Yes ___ No If yes, please explain on separate sheet.


9. Claims Experience

    a. Do any principals, directors, officers, partners, professional employees or independent contractors of the
         Applicant have knowledge or information of any act or omission which might reasonably be expected to
         give rise to a claim? ___ Yes ___ No
    b. Has the Applicant, or any of its predecessors in business, subsidiaries or affiliates, or any of the principals,
         directors, officers, partners, professional employees or independent contractors ever been the subject of a
         disciplinary action as a result of professional activities? ___ Yes ___ No
    c. During the past five years, have any claims or suits been made against the Applicant, any predecessors in
         business, subsidiaries, affiliates or any principal, director, officer or professional employee? ___ Yes ___
         No
    d. Has the Applicant reported the matters listed in Question 10a-c to its current or former insurance carrier?
         ___ Yes ___ No
    If yes to any part of Question 10a-c, please complete a Supplemental Claims Questionnaire for each claim,
    notice or circumstance.
    e. The basic policy for which you have applied will not cover acts committed before the inception date of the
       Policy. If you desire a quote for these prior acts, please enter the date from which you want prior acts
       covered:_______________________________________________________________________________

    Note that coverage does not apply to known or expected claims or those which any insured could have
    foreseen.

10. The Applicant is to attach samples of its promotional materials and standard contracts utilized.
    Samples attached? ___ Yes ___ No If no, please explain on separate sheet.




MPL 14001 (02/06)                                                                                    Page 2 of 3
NOTICE TO APPLICANT – PLEASE READ CAREFULLY

If Ace Insurance Company of Puerto Rico (We / Us / the Company) grants coverage, it would have relied
upon the declarations and statements in this application for coverage.       All such declarations and
statements are the basis of coverage and will be considered incorporated in and constituting part of the
policy should one be issued.

The undersigned authorized representative of the Applicant firm, based upon reasonable inquiry, warrants
to the best of its knowledge that the statements set forth herein are true and include all material
information. The Applicant further warrants that, if the information supplied on this application changes
between the date of this application and the effective date of the insurance, the undersigned will, in order
for the information to be accurate on the effective date of the insurance, immediately notify Us of such
change(s), and the Company may withdraw or modify any outstanding quotations and authorization or
agreements to bind the insurance.

Signing of this application does not bind the firm or the Company to complete the insurance, but it is
agreed that this application will be the basis of the contract should a policy be issued, and it will become
part of the policy as if physically attached. All supplements, written statements and other material
furnished to the Company in conjunction with this application are hereby incorporated by reference into
this application and made a part hereof. Nothing contained or incorporated herein by reference will
constitute notice of a claim or potential claim so as to trigger coverage under any contract of insurance.

ANY PERSON WHO KNOWINGLY AND WITH THE INTENT TO DEFRAUD, PRESENTS FALSE
INFORMATION IN AN INSURANCE REQUEST FORM, OR WHO PRESENTS, HELPS OR HAS PRESENTED A
FRAUDULENT CLAIM FOR THE PAYMENT OF A LOSS OR OTHER BENEFIT, OR PRESENTS MORE THAN
ONE CLAIM FOR THE SAME DAMAGE OR LOSS, WILL INCUR A FELONY, AND UPON CONVICTION WILL
BE PENALIZED FOR EACH VIOLATION WITH A FINE OF NO LESS THAN FIVE THOUSANDS DOLLARS
($5,000) NOR MORE THAN TEN THOUSANDS ($10,000); OR IMPRISONMENT FOR FIXED TERM OF THREE
(3) YEARS, OR BOTH PENALTIES.     IF AGGRAVATED CIRCUMSTANCES PREVAIL, THE FIXED
ESTABLISHED IMPRISONMENT MAY BE INCREASED TO A MAXIMUM OF FIVE (5) YEARS; IF
ATTENUATING CIRCUMSTANCES PREVAIL, IT MAY BE REDUCED TO A MINIMUM OF TWO (2) YEARS.




          Date                                                               Signature




MPL 14001 (02/06)                                                                          Page 3 of 3

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:0
posted:4/23/2013
language:Unknown
pages:3