Specified Professions Professional Liability Product

BUSINESS OWNERS SUPPLEMENTAL PACKAGE ADDENDUM

If you DO NOT currently carry general liability and/or property insurance with United States Liability Insurance Group and would like a quotation, please complete the following questions:

Applicant Name:*

Prefix First Last Suffix

Address*

Street Address Address Line 2 City State ZIP Code

1. Has the applicant had any general liability claims paid, reserved or pending in the last five years?*

Yes
No

If “Yes,” please provide details:

2. Additional insured(s) to be included on general liability:*

Name:	Relationship to Applicant	Address:

Please use the + button to the right to add additional Insured(s)

3. Personal property limit, including computer hardware (at 80% coinsurance/replacement cost):*

4. Building Characteristics: (a) Are functioning burglar alarms present?*

Yes
No

(b) Is the electrical system connected to circuit breakers?*

Yes
No

(c) Are functioning smoke detectors and fire alarms present?*

Yes
No

(d) Is aluminum wiring present in the building?*

Yes
No

5. Has the applicant had any property claims paid, reserved or pending in the last five years?*

Yes
No

If “Yes,” please provide details:

This supplemental application is subject to the same provisions concerning representations made in the general application originally submitted to obtain professional liability insurance.

Signature:*

(Principal, Partner or Officer)

Title:*

Date:*

This document does not amend, extend or alter the coverage afforded by the Policy. For a complete understanding of any insurance you purchase, you must first read your Policy, Declaration Page and any Endorsements and discuss them with your Broker. A specimen policy is available from an Agent of the Company. Your actual Policy Conditions may be amended by Endorsement or affected by State Laws.

Business Owners Supplement

Business Owners Supplement

Specified Professions Professional Liability Product

BUSINESS OWNERS SUPPLEMENTAL PACKAGE ADDENDUM