ACCOUNTANTS BASIC COVERAGE – ABC
PROFESSIONAL LIABILITY SELF- RATING APPLICATION
Territory 1 FL. IL. MN. OH.
This application is for a claims –made insurance policy.
Please read the policy carefully. It contains important exclusions and conditions to your insurance coverage.
Please direct questions to YOUR AGENT or the National Administrator Herbert H. Landy Insurance Agency.
Answer each question completely. Do not use pencil. A principal of the firm must sign the application. Use whole numbers
where percentages are indicated.
Follow the self-rating instructions for premium calculation. Select and initiate payment option.
We retain the right to decline coverage and return your payment if the answers to the questions do not meet the program
1. Applicant Information
Firm Name ________________________________________________ Date Firm Established: ______/_____/_______
Contact Person at Firm ____________________________________________________________________________
Principal Business Address__________________________________________________________________________
Phone ( ) __________________________
Fax ( ) __________________________
Desired Effective Date: ____/_____/______
E-Mail Address _______________________________________________
□ In lieu of mailing my policy, you may e-mail my policy to the above address. I agree to accept an electronic copy of my
application with my policy.
2. Check the limit of liability desired. A standard deductible of $1,000 applicable to losses and expenses will be given
Claim expenses outside the limits and loss only deductible are mandatory in New York.
□ $100,000/$200,000 □ $250,000/$500,000 □ $500,000/$500,000 □