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SR 16 17/EF 10/99
® A registered trademark of SAFECO Corporation
DOC
GENERAL INSURANCE COMPANY OF AMERICA
HOME OFFICE: SAFECO PLAZA, SEATTLE, WASHINGTON 98185
Insurance Professionals Errors and Omissions Liability
Basic Application for Claims Made and Reported Coverage
1. Name of Applicant Firm (include all Named Insured legal entities):
Address:
Contact Person: E-mail Address:
Phone: Fax:
Named insured is a(n):
Corporation
Partnership
LLC
Individual
Other
2. How many total office locations do you have?
one
two
three
3a. Do you belong to an agency cluster? .......................................................................................................................................................................................
Yes
No
3b. Have there been any mergers or acquisitions with othe