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Application for Professional Liability Coverage

This is an Application for a Claims Made and Reported Policy. There is no coverage for acts or omissions committed prior to the date insurance is first purchased unless Prior Acts Coverage is also purchased.

You can apply using the electronic application starting below, or by downloading and printing this pdf application. If you choose the latter, please scan your completed and signed application to LVitullo@TargetProIns.com, or fax it to 866-720-5003.
Note that in most cases, completion of the electronic application below will generate a premium amount, and upon payment, you’ll receive an immediate proof of insurance. We will respond to all other applications as quickly as possible.

This program is available in all states.
  1.  Is this application for a new policy or a renewal of an existing policy?  
2. If question 1 is "Existing Policy", this is my ; renewal.
  3.  a) Full Name of Applicant
 
b) Agency Name: (For applications with multiple agents you must supply a valid DBA or trade name.)
   
  4. Principal Business Address: (Physical address only, PO Box not accepted)
  Address:
  City:   State:   ZIP:
  5. Phone # Fax #:
  E-Mail:
Password:     This field cannot be blank.
 Number of Agents to be covered including principal.