PRIVATE INVESTIGATOR PROFESSIONAL LIABILITY INSURANCE APPLICATION

---

NOTICE: THIS IS A CLAIMS-MADE FORM: EXCEPT TO SUCH EXTENT AS MAY OTHERWISE BE PROVIDED HEREIN, THE COVERAGE OF THIS POLICY IS LIMITED TO LIABILITY FOR ONLY THOSE CLAIMS THAT ARE FIRST MADE AGAINST THE INSURED AND REPORTED IN WRITING TO THE COMPANY WHILE THE POLICY IS IN FULL FORCE. PLEASE REVIEW THE POLICY CAREFULLY. COVERAGE IS WRITTEN ON A SURPLUS LINES BASIS. RATES SHOWN BELOW ARE FOR APPLICANTS GENERATING LESS THAN $150,000 IN RECEIPTS ANNUALLY. APPLICANTS GENERATING HIGHER ANNUAL RECEIPTS MUST COMPLETE THE FULL APPLICATION SO THEY CAN BE INDIVIDUALLY UNDERWRITTEN AND RATED.

Select Limit of Liability Deductible Premium Taxes & Fees (Req'd) Total Due (Premiums+Fee)   $ 500,000 / $ 500,000 $ 5,000 $ 750 +$175 $ 925   $1,000,000 / $1,000,000 $ 5,000 $ 1,000 +$175 $ 1,175

1.	GENERAL INFORMATION
	Applicant Name:
	Business Address:
	City:		State:	--Select One-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming	Zip:
	Phone:	() -	Fax:	() -
	Email:
	Do you operate from a residence?	Yes No
	Years in Business:		Date Business Established:
	Does Applicant have employees or retain independent contractors?		Yes No	If "Yes", how many?

2.	FINANCIAL AND BUSINESS INFORMATION
	a. Total receipts, last 12 months:		$
	b. Provide professional services by approximate percentage. Must equal 100%.
	Service Provided	%	Service Provided	%	Service Provided	%
	Activity Check		Domestic		Product Liability
	Criminal		Process Service		Claims Adjuster
	Polygraph		Attorney Service		Consulting
	AOE/COE		Fidelity		Property/Arson
	Civil		Record Retrievers		Computer Fraud
	Locates/Skip Tracing		Background/Credit Check		Medical Malpractice
	Forensic Investigation		Other (describe):
	Indicate on whose behalf services are performed. Must equal 100%.
	Client	%	Client	%	Client	%
	Insurance Carriers		Private Parties		Law Firms
	Public Entities		Self Insureds		Professional Sports Teams
	Other (describe):
	c. State License No.:
	License Type:
	d. Applicant is:	Individual Partnership Corporation Other (describe)

3.	PRIOR INSURANCE
	a.	Do you currently have an Errors & Omissions Insurance policy?		Yes No
		If "Yes", specify carrier:		Retroactive Date:
	b.	Has any Errors & Omissions or Professional Liability Insurance issued to the Applicant ever been declined, cancelled, or non-renewed?			Yes No
		If "Yes", please explain
	c.	Has any Professional Liability claim(s), complaint or proceeding been made against the Applicant or any person or organization proposed for this insurance or any predecessor organization?			Yes No
		If "Yes", please explain

PAYMENT OPTIONS
	A.	Check For Full Amount Due, Payable to Fox Point Programs, Inc.
	B.	Credit Card:	VISA  Mastercard  AMEX	Card Number:
				Expiration Date:	01 02 03 04 05 06 07 08 09 10 11 12 / 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024
	Applicant Statement & Agreement
			By checking this box, I attest that all information that I have provided on this application or any other document filled out in connection with it is true and correct.  I have withheld nothing that would, if disclosed, affect this application unfavorably.   Checking this box indicates my signature as agreement to these terms.