BMP Insurance Services

Professional Liability Insurance Quote

Professional liability insurance provides protection against claims that the policyholder becomes legally obligated to pay as a result of an error or omission in his professional work. Also known as "Errors and Omissions" insurance, this type of professional liability insurance is critical to your business. E&O insurance responds to claims of professional liability in the delivery of your technical services. Allow us to customize an errors and omissions insurance policy for you that is affordable and effective.

APPLICANT INFORMATION
Your Name:
Your E-Mail Address:
Street Address:
City:
State:
ZIP Code:
Date of Birth:

PROFESSIONAL INFORMATION
Occupation:
Specialty:
Practice Type:
Practice Operates:	Full Time Part Time
Board Certified:	Yes No
License Number:

CURRENT PROFESSIONAL LIABILITY INSURANCE
Current Insurance Carrier:
Limit of Liability Per Claim ($):
Limit of Liability Aggregate ($):
Effective Date:
Retroactive Date:
Premium:

CLAIMS HISTORY
This information is kept strictly confidential.
CLAIM 1
Claim Status:	Open Closed
Claimant Name:
Date of Occurrence:
Insurance Carrier:
Location of Occurrence:

Allegations:
Paid on Your Behalf:
Reserved on Your Behalf:

CLAIM 2
Claim Status:	Open Closed
Claimant Name:
Date of Occurrence:
Insurance Carrier:
Location of Occurrence:

Allegations:
Paid on Your Behalf:
Reserved on Your Behalf:

CLAIM 3
Claim Status:	Open Closed
Claimant Name:
Date of Occurrence:
Insurance Carrier:
Location of Occurrence:

Allegations:
Paid on Your Behalf:
Reserved on Your Behalf:
Additional Comments: