Occurrenceor Claims Made:
Retroactive Date(N/A if Occurrence):
Limits of Liability:
Coverage Effective Date:
Coverage Expiration Date:
Have you taken a risk management course within the past three years?
Do you practice part-time(20 hours per week or less)?
Expiring or renewal premium?:
Please identify and explain any gaps in coverage:
Number of open claims:
Number of closed claims:
Total Paid or Settled Amount: