ASFMRA Professional Liability Application
PLEASE PRINT THIS APPLICATION, COMPLETE,  MAIL or FAX TO:
Midwest Insurance Consultants, Ltd.
Box 58
Nevada, IA 50201
Phone: 1-800-729-4341    Facsimile: 1-515-382-3844

This is an application for a "claims made" policy

1.
A) Name of Applicant:_______________________________
B) Name of all Subsidiaries/Affiliates:
_____________________________________________
(Contact Person:________________________________)
2. Address: __________________________________________
3. City: ____________________  State: ____  Zip Code: _______
4. Phone: __________________  FAX: ____________________
5. Date Established: ___/___/___
Corporation ___     Partnership ___     Individual ___
6. During the past five years has the name of the applicant been changed or has any other business been purchased, merged or consolidated with the applicant?
Yes ___     No ___

If yes, please explain:________________________________
__________________________________________________

7. Is the applicant controlled, owned, or managed by any other firm, corporation, or company?   Yes ___  No ___
If yes, please explain: _______________________________
__________________________________________________
8. Does the applicant have any foreign operations?
Yes ___  No ___

If yes, list the countries and the percentage of  gross receipts applicable to each country:
__________________________________________________
__________________________________________________
9. Describe in detail all professional or business activities that you provide and indicate percentage of gross receipts derived from each activity.

NOTE: The descriptions used here will become part of your policy and will be used to describe the types of professional services that are insured.

Activity

% of Receipts

_______________________________________________
_______________________________________________ _______________________________________________
_______________________________________________
10.
A) List below the number of all staff

Full Time

Part Time
Principals, partners & owners _______ _______
All other professional staff _______ _______
Support staff _______ _______
B) Gross Revenues
This Year $__________   Last Year $ __________
C) Are consultants hired on an "Independent Contractor" basis?
Yes____  No ____
If so, please list which are:_________________________
11.
A) Does your firm regularly retain subcontractors or other outside sources to fulfill engagements to clients?
Yes ___  No ___
If  yes, please explain: _____________________________________________________
_____________________________________________________
B) What is the cost of subcontractors?
Last 12 months: _______     Next 12 months: ________
C) Do you require certificates of professional liability or other evidence of financial responsibility from subcontractors?  Yes  or  No

If yes, what is the minimum limit of liability that you would require the contractor to carry?  ______________
12. Does the applicant subcontract services to others?
Yes ___   No ___

If yes explain what type of services and what percentage of your total gross receipts are subcontracted.
____________________________________________
____________________________________________
13. Does any person to be insured serve on the Board of any client of the applicant?
Yes ___  No ___

If  so please explain.
________________________________________________
________________________________________________
14. List all of the professional organizations or societies of which the firm is a member.  If none, state "none".
________________________________________________
________________________________________________
15. Do you subscribe to a published professional code of ethics?
Yes ___   No ___    If so, please attach copy
16 Does the applicant  use a written contract that specifies the services provided?
Yes ___   No ___
If yes, is the contract a standard contract used for all engagements or is it customized for each engagement?   Standard ___  Custom ___

For what percentage of total engagements is the contract used? ________%

Does the contract contain:

A.


A specific description of the services you provide? Yes ___


 No ___
B. Guarantees or warranties? Yes ___ No ___
C. An estimate of the fee to be charges? Yes ___ No ___
D. Disclaimers? Yes ___ No ___
E. A remediation or alternative dispute resolution clause? Yes ___ No ___
F. Hold harmless or indemnification clause? Yes ___ No ___
17. Does the applicant and all members of the firm that provide professional service:
A. Keep written record of important verbal instructions and oral agreements in the client file? Yes ___ No ___
B. Keep written file documentation that detail actions, procedures and decisions that are made on client accounts? Yes ___ No ___
C. Conduct peer review of all major engagements with at least on other professional that will not be providing the service? Yes ___ No ___
D. Consult with outside experts in areas that are not the applicant's expertise or are especially complex? Yes ___ No ___
E. Have a client screening process? Yes ___ No ___
F. Require advance fee negotiation, explanation and documentation? Yes ___ No ___
G. Have a policy against the use of a collection agency for overdue fee except as a last resort? Yes ___ No ___
H. Have procedures in place to provide the client with regular progress reports? Yes ___ No ___
I. Have guidelines that specify the conditions and circumstances under which clients must be rejected due to potential conflict of interest? Yes ___ No ___
J. Have procedures that preserve the confidential nature of the client-professional relationship? Yes ___ No ___
K. Have an in-house training program for all new employees? Yes ___ No ___
18. Has your firm in the past five years ever been dismissed from an assignment prior to completion?   Yes___ No ___
If so, please explain:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
19.
A) What percent of your present business was developed from clients for whom you have done work in the previous three years?
__________%
B) What is the average number of assignments per consultant at any given time? _____
20. Have you in the past, or are you presently, acting in the capacity as an administrator, manager, sales person or exercising decision making authority for a client or assignment?
Yes ___ No ___
If yes, please explain. ____________________________________________
_______________________________________________________________
_______________________________________________________________
21.
A) Is the applicant engaged in any other business or profession?
Yes___ No ___
If yes, please explain. ____________________________________________
_______________________________________________________________
_______________________________________________________________
B) Do any of the applicant's principals serve in any capacity with any other business or corporation?
Yes___ No ___
If yes, please explain. ____________________________________________
_______________________________________________________________
_______________________________________________________________
22. List all similar insurance carried during the past three years. If none, state "none".
Company
_____________
_____________
_____________		 Limits
_____________
_____________
_____________		 Deductible
_____________
_____________
_____________		 Premium
_____________
_____________
_____________		 Policy Period
_____________
_____________
_____________

Retro date on current policy (if applicable): _________________________
23. Have any claims or suits been made during the past five (5)  years against the applicant or any of its predecessors in business, or any of the past or present partners, owners, officers or employees?
Yes ___ No ___
If yes, attach a statement giving details and status of each claim including dates, amount of claim, deductibles, payments and open reserves.
24. Is the applicant, after inquiry of each person proposed for insurance, aware of any circumstance, error, omission or offense which may result in a claim being made against the applicant or any of its predecessors in business, or any of the past or present partners, owners, officers or employees?
Yes___ No___
If yes, please explain. ____________________________________________
_______________________________________________________________
_______________________________________________________________
25. Circle the amount of liability desired:
$100,000 ,  $250,000,  $500,000,  $750,000 or $1,000,000

Requested Effective Date:   ____/____/____

26. The undersigned being authorized by, and acting on behalf of, the applicant and all persons or concerns seeking insurance, has read and understands this application, and declares all statements set forth herein are true, complete and accurate. The undersigned further declares and represents that any occurrence or event taking place prior to the effective date of the policy applied for, which may render inaccurate, untrue, or incomplete any statement made herein will be immediately reported in writing to the insurer. The undersigned acknowledges and agrees that the submission and the insurer's receipt of such written report, prior to the inception of the policy applied for, is a condition precedent to coverage.
The signing of this application does not bind the undersigned to purchase the insurance, nor does review of the application bind the insurance company to issue a policy. It is agreed that this application shall be the basis of the contract should a policy be issued.
Date: ____________________________________
Signed: ____________________________________
Title: ____________________________________
27. Please attach copies of the following:
A. Advertisements, brochures, descriptive literature
B. Sample contract between the applicant and clients outlining services to be rendered
C. Latest financial information (if not available, please explain).

Attach an additional sheet where necessary and declare any additional comments.
FARM MANAGEMENT CONSULTANT SUPPLENMENTAL INFORMATION
I. FIRM SIZE:

Active

Inactive

Full Time

Part Time
Principals _______ _______ _______
Accredited Farm Managers _______ _______ _______
Accredited Rural Appraisers _______ _______ _______
Real Property Review Appraisers _______ _______ _______
Other Professionals _______ _______ _______
Other employees _______ _______ _______

TOTALS

Provide a list of current staff, including job title and professional designations.

 
II. MIX OF BUSINESS (last 12 months):

Gross Revenues

Transactions
Farm Sales/Leasing - Real Property

_____________

 _____________
Rural Land Sales _____________ _____________
Farm Brokerage - Business _____________ _____________
Farm Management _____________ _____________
Farm Planning/Consulting _____________ _____________
Rural Appraisals _____________ _____________
Appraisal Review _____________ _____________
Other (describe on separate sheet) _____________ _____________

 

 
III. QUALIFYING QUESTIONS:  If you answer yer to any of the following questions, please attach a brief explanation of the circumstances on a separate sheet.
A. Has you, or anyone else in your firm, ever been subject to any form of disciplinary action? 
Yes___ No ___
B. Have you, or any member(s) of your firm, ever been denied, cancelled or refused professional liability (E&O) Insurance before?
Yes ___  No ___
C. Do you participate in any of the following excluded activities:
Building or Developing:  Group Investments/Syndications (REITs); Accounting Audits (CPA); Insurance Sales or any activities you have a personal interest in?
Yes ___  No ___
D. Do you have any other commercial insurance in force (CGL, BOP, Inland Marine, other Professional Liability coverage, etc.)
Yes ___  No ___

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