DHH Insurance Agency, LLC

DHH Insurance Agency, LLC

Call: 1.866.371.8830

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A Division of C.H. Insurance Brokerage, Inc.www.chinsurance.cc

RID's Sign Language Interpreter Insurance Program Online Application

A. Please answer ALL the questions.
B. This supplement must be signed and dated by the prospective insured and will be attached to the policy, should one be issued. A digital signature will be used on the online application.

* Denotes Required Fields

Are you a member in good standing of The Registry of Interpreters for the Deaf(RID)?*

Certifications (check all that apply):

Have you completed and passed The Registry of Interpreters for the Deaf (RID) written & performance test for:

Are you required to be licensed in your state?

What percentage of your gross annual revenues are derived from the type of client or material type below:

List the top four clients or agencies you have contracted with and the hours worked over the past 12 months.

Do you currently have Professional Liability / Errors and Omissions insurance?

Prior Litigation / Claims

Have you been subject to any professional discipline, claims, suits, or demands for arbitration within the past five(5) years?

Are you aware of any act, error, omission, unresolved job dispute or any other circumstances that could be a basis for a claim under this proposed insurance?

It is understood and agreed that if any such claim, act, error, omission, dispute or circumstance exists, then such claim and/or claims arising from such act, error, omission, dispute or circumstance is excluded from coverage that may be provided under this proposed insurance and, further, failure to disclose such claim, act, error, omission, dispute or circumstance may result in the proposed insurance being void, and/or subject to rescission.