Directors & Officers Insurance

Application

Submission

Confirmation

Coverage Type	Limit of Liability	Retention	Premium
Directors and Officers	{{Variables.limit \| currency:"$"}}	{{Variables.selectedretention\| currency:"$"}}	{{Variables.DOPremium \| currency:"$"}}
Employment Practices	{{Variables.limit \| currency:"$"}}	{{Variables.selectedretention\| currency:"$"}}	{{Variables.EPLIPremium \| currency:"$"}}
Fiduciary	{{Variables.limit \| currency:"$"}}	{{Variables.selectedretention \| currency:"$"}}	{{Variables.FLIPremium \| currency:"$"}}

{{discount.OnlineDescription}}		{{discount.OnlineDiscount}}%	{{ Variables.Discounts \| currency:"$ "}}
Premium Subtotal			{{ Variables.SubTotal \| currency:"$ "}}
Taxes	{{Variables.StateTaxDescription}}	{{Variables.StateTaxRate*100 \| number :2}}%	{{Variables.SubTotal*Variables.StateTaxRate \| number :2 \| currency:"$"}}
Taxes	{{Variables.CityTaxDescription}}	{{Variables.CityTaxRate*100 \| number :2}}%	{{Variables.SubTotal*Variables.CityTaxRate \| currency:"$"}}

Total			{{ Variables.Total \| currency:"$"}}

Save & Generate Proposal

Payment Information

Card Type

{{Purchase.Valids.CardType.message}}

Card number

{{Purchase.Valids.NumberCard.message}}

Name on Card

{{Purchase.Valids.CardName.message}}

Expires on Month:

{{Purchase.Valids.Month.message}}

Expires on Year:

{{Purchase.Valids.Year.message}}

Security Code: What is this?

{{Purchase.Valids.SecurityCode.message}}

Billing Address

Same as Insured

Address	City	Zipcode	State
{{Variables.address}} {{Variables.address2}}	{{Variables.city}}	{{Variables.zipcode}}	{{Variables.state}}

Address		City	Zipcode	State
{{Purchase.Valids.Address1.message}}		{{Purchase.Valids.City.message}}	{{Purchase.Valids.Zip.message}}	{{Purchase.Valids.State.message}}

Total: $ {{Variables.Total | number:2}}

Submit

Message:{{Purchase.Result.Message}}

Submit

Premium 1	Premium 2	Premium 3
{{Variables.Premium01 \| currency:"$"}}	{{Variables.Premium02 \| currency:"$"}}	{{Variables.Premium03 \| currency:"$"}}

Premium Subtotal			{{ Variables.SubTotal \| currency:"$ "}}
Taxes	{{Variables.StateTaxDescription}}	{{Variables.StateTaxRate*100 \| number :2}}%	{{Variables.StateTaxTotal \| number :2 \| currency:"$"}}
Taxes	{{Variables.CityTaxDescription}}	{{Variables.CityTaxRate*100 \| number :2}}%	{{Variables.CityTaxTotal \| currency:"$"}}

Total			{{ Variables.Total \| currency:"$"}}

Submit

Uncheck the "Apply Payment in Nexsure box" if this is a partial payment or a split of two payment methods (credit card and check or 2 checks). For all PHLY Special event manual payments (American Express and Wires) uncheck the Apply Payment in Nexsure box).

TOTAL $	Payment Amount	Apply Payment in Nexsure
$ {{Variables.Total}}		Yes No

Policy Effective Date	E-mail Policy Documents to Client	Client E-mail
{{Variables.EffDate \| date}}	Yes No	{{Variables.Email}}

Submit

Policy Effective Date	Send Email	Has binding conditions?
{{Variables.EffDate \| date}}	Yes No	Yes No

Submit

Pending reason

Pend template

Select a reason

Please be advised that the payment submitted with your application was insufficient.
Please send the additional amount owed: $

Note: Please send a check or money order. You may pay by Visa or MasterCard over the phone, if the amount owed is $30.00 or more.

Please contact our office to clarify your staff.

Please contact our office to clarify your occupation and/or employment category.

Note: Please complete the attached qualification questions and/or signature field that were left blank on your application. (Qualification questions will be added into the PDF and Email)

Policy Effective Date	E-mail pending reason to client
{{Variables.EffDate \| date}}	Yes No

Submit

Rates Table

Showing 6 of 10 levels. Click here for show all levels.

Coverage / Level	1	2	3	4	5	6	7	8	9	10
{{level.NewColumn}}	${{level.Level1}}	${{level.Level2}}	${{level.Level3}}	${{level.Level4}}	${{level.Level5}}	${{level.Level6}}	${{level.Level7}}	${{level.Level8}}	${{level.Level9}}	${{level.Level10}}
Please select your desired coverage level by clicking one of the following radio buttons.

Renewing Customers

Do you have a current Professional Liability Insurance Policy for Life Coaches with Philadelphia Insurance Company?

Yes No

Please enter your policy number or email address

Searching...

Your entry does match a record in our system:

Policy Number: {{userFound.PolicyNumber}}
Email address: {{userFound.Email}}
Current Retroactive date: {{userFound.RetroactiveDate}}
Current Effective date: {{userFound.EffectiveDate}}

Please proceed to complete remaining information in order to renew your policy.

We’re sorry, but your entry does not match a record in our system.
Please contact us at 800-875-1911 to retrieve your policy information.

Searching...

We’re sorry, but your entry does not match a record in our system.
Please contact us at 800-875-1911 to retrieve your policy information.

Submit

Payment Information

*Card Type: {{Purchase.Valids.CardType.message}}

*Card Number: {{Purchase.Valids.NumberCard.message}}

Shopping is always safe and secure

*Expires On:

{{Purchase.Valids.Year.message}} {{Purchase.Valids.Year.message}}

*Security Code: What is this? {{Purchase.Valids.SecurityCode.message}}

*Name on Card: {{Purchase.Valids.CardName.message}}

Gross Payment
Net Payment

Total: {{(!Variables.IsGrossPayment ? 0.80*Variables.TotalPremium + Variables.TotalTax + (Variables.Fee ? Variables.Fee : 0) : Variables.Total) | currency}}

Billing Address

Same as Insured:

{{Variables.orgName}}
{{Variables.address + ","}} {{Variables.address2}}
{{Variables.city + ","}} {{Variables.state}} {{Variables.zipcode}}

Street Address 1: {{Purchase.Valids.Address1.message}}*	Street Address 2:

City: {{Purchase.Valids.City.message}}*	State: {{Purchase.Valids.State.message}}*

Zip Code: {{Purchase.Valids.Zip.message}}*

Message:{{Purchase.Result.Message}}

Policy Effective Date	E-mail Policy Documents To Client
{{Variables.EffDate \| date}}	Yes No

Submit

Policy Effective Date	E-mail decline reason to client
{{Variables.EffDate \| date}}	Yes No

Submit

In order to Bind Coverage you must generate a proposal
and accept the terms and conditions of the policy.

Save Application and Generate a Proposal

Submit

Effective Date	Send Email
{{Variables.EffDate \| date}}	Yes No

Submit

Bind Coverage

Add another

{{row.MultiAnswerLabel}} Review errors Remove

Add another

Prev step {{nextStepText}}

Coverage Type	Limit of Liability	Retention	Premium
Directors and Officers	{{Variables.limit \| currency:"$"}}	{{Variables.selectedretention\| currency:"$"}}	{{Variables.DOPremium \| currency:"$"}}
Employment Practices	{{Variables.limit \| currency:"$"}}	{{Variables.selectedretention\| currency:"$"}}	{{Variables.EPLIPremium \| currency:"$"}}
Fiduciary	{{Variables.limit \| currency:"$"}}	{{Variables.selectedretention \| currency:"$"}}	{{Variables.FLIPremium \| currency:"$"}}

{{discount.OnlineDescription}}		{{discount.OnlineDiscount}}%	{{ Variables.Discounts \| currency:"$ "}}
Premium Subtotal			{{ Variables.SubTotal \| currency:"$ "}}
Taxes	{{Variables.StateTaxDescription}}	{{Variables.StateTaxRate*100 \| number :2}}%	{{Variables.SubTotal*Variables.StateTaxRate \| number :2 \| currency:"$"}}
Taxes	{{Variables.CityTaxDescription}}	{{Variables.CityTaxRate*100 \| number :2}}%	{{Variables.SubTotal*Variables.CityTaxRate \| currency:"$"}}

Total			{{ Variables.Total \| currency:"$"}}

Save & Generate Proposal

Payment Information

Card Type

{{Purchase.Valids.CardType.message}}

Card number

{{Purchase.Valids.NumberCard.message}}

Name on Card

{{Purchase.Valids.CardName.message}}

Expires on Month:

{{Purchase.Valids.Month.message}}

Expires on Year:

{{Purchase.Valids.Year.message}}

Security Code: What is this?

{{Purchase.Valids.SecurityCode.message}}

Billing Address

Same as Insured

Address	City	Zipcode	State
{{Variables.address}} {{Variables.address2}}	{{Variables.city}}	{{Variables.zipcode}}	{{Variables.state}}

Address		City	Zipcode	State
{{Purchase.Valids.Address1.message}}		{{Purchase.Valids.City.message}}	{{Purchase.Valids.Zip.message}}	{{Purchase.Valids.State.message}}

Total: $ {{Variables.Total | number:2}}

Submit

Message:{{Purchase.Result.Message}}

Submit

Premium 1	Premium 2	Premium 3
{{Variables.Premium01 \| currency:"$"}}	{{Variables.Premium02 \| currency:"$"}}	{{Variables.Premium03 \| currency:"$"}}

Premium Subtotal			{{ Variables.SubTotal \| currency:"$ "}}
Taxes	{{Variables.StateTaxDescription}}	{{Variables.StateTaxRate*100 \| number :2}}%	{{Variables.StateTaxTotal \| number :2 \| currency:"$"}}
Taxes	{{Variables.CityTaxDescription}}	{{Variables.CityTaxRate*100 \| number :2}}%	{{Variables.CityTaxTotal \| currency:"$"}}

Total			{{ Variables.Total \| currency:"$"}}

Submit

TOTAL $	Payment Amount	Apply Payment in Nexsure
$ {{Variables.Total}}		Yes No

Policy Effective Date	E-mail Policy Documents to Client	Client E-mail
{{Variables.EffDate \| date}}	Yes No	{{Variables.Email}}

Submit

Policy Effective Date	Send Email	Has binding conditions?
{{Variables.EffDate \| date}}	Yes No	Yes No

Submit

Pending reason

Pend template

Select a reason

Please be advised that the payment submitted with your application was insufficient.
Please send the additional amount owed: $

Note: Please send a check or money order. You may pay by Visa or MasterCard over the phone, if the amount owed is $30.00 or more.

Please contact our office to clarify your staff.

Please contact our office to clarify your occupation and/or employment category.

Note: Please complete the attached qualification questions and/or signature field that were left blank on your application. (Qualification questions will be added into the PDF and Email)

Policy Effective Date	E-mail pending reason to client
{{Variables.EffDate \| date}}	Yes No

Submit

Rates Table

Showing 6 of 10 levels. Click here for show all levels.

Coverage / Level	1	2	3	4	5	6	7	8	9	10
{{level.NewColumn}}	${{level.Level1}}	${{level.Level2}}	${{level.Level3}}	${{level.Level4}}	${{level.Level5}}	${{level.Level6}}	${{level.Level7}}	${{level.Level8}}	${{level.Level9}}	${{level.Level10}}
Please select your desired coverage level by clicking one of the following radio buttons.

Renewing Customers

Do you have a current Professional Liability Insurance Policy for Life Coaches with Philadelphia Insurance Company?

Yes No

Please enter your policy number or email address

Searching...

Your entry does match a record in our system:

Policy Number: {{userFound.PolicyNumber}}
Email address: {{userFound.Email}}
Current Retroactive date: {{userFound.RetroactiveDate}}
Current Effective date: {{userFound.EffectiveDate}}

Please proceed to complete remaining information in order to renew your policy.

We’re sorry, but your entry does not match a record in our system.
Please contact us at 800-875-1911 to retrieve your policy information.

Searching...

We’re sorry, but your entry does not match a record in our system.
Please contact us at 800-875-1911 to retrieve your policy information.

Submit

Payment Information

*Card Type: {{Purchase.Valids.CardType.message}}

*Card Number: {{Purchase.Valids.NumberCard.message}}

Shopping is always safe and secure

*Expires On:

{{Purchase.Valids.Year.message}} {{Purchase.Valids.Year.message}}

*Security Code: What is this? {{Purchase.Valids.SecurityCode.message}}

*Name on Card: {{Purchase.Valids.CardName.message}}

Gross Payment
Net Payment

Total: {{(!Variables.IsGrossPayment ? 0.80*Variables.TotalPremium + Variables.TotalTax + (Variables.Fee ? Variables.Fee : 0) : Variables.Total) | currency}}

Billing Address

Same as Insured:

{{Variables.orgName}}
{{Variables.address + ","}} {{Variables.address2}}
{{Variables.city + ","}} {{Variables.state}} {{Variables.zipcode}}

Street Address 1: {{Purchase.Valids.Address1.message}}*	Street Address 2:

City: {{Purchase.Valids.City.message}}*	State: {{Purchase.Valids.State.message}}*

Zip Code: {{Purchase.Valids.Zip.message}}*

Message:{{Purchase.Result.Message}}

Policy Effective Date	E-mail Policy Documents To Client
{{Variables.EffDate \| date}}	Yes No

Submit

Policy Effective Date	E-mail decline reason to client
{{Variables.EffDate \| date}}	Yes No

Submit

In order to Bind Coverage you must generate a proposal
and accept the terms and conditions of the policy.

Save Application and Generate a Proposal

Submit

Effective Date	Send Email
{{Variables.EffDate \| date}}	Yes No

Submit

Bind Coverage

Add another

{{row.MultiAnswerLabel}} Review errors Remove

Add another

Quote Number: {{LogWF.QuoteNumber}}

Policy Number: {{LogWF.PolicyNumber}}

Please select an address from the list below:

Street	City	Zipcode	State
{{a.ParsedAddressRange }} {{a.StreetName}} {{a.Suffix}}	{{a.City}}	{{a.Zip}}	{{a.State}}

Cancel

Please enter a valid suite, or unit and number and click "update".

Please enter a valid address.

Address 1

Address 2

City

State

Zipcode

Please select the best match below:

Street	Street 2	City	Zipcode	State
{{a.Line1 }}	{{a.Line2}}	{{a.City}}	{{a.PostalCode}}	{{a.StateProvince}}

Street	Street 2	City	Zipcode	State
{{ValidatingAddress.Line1 }}	{{ValidatingAddress.Line2}}	{{ValidatingAddress.City}}	{{ValidatingAddress.ZipCode}}	{{ValidatingAddress.StateProvince}}

Do not update, use address as entered:
{{EnteredAddress.Line1}} {{EnteredAddress.Line2}}, {{EnteredAddress.City}} {{EnteredAddress.StateProvince}} {{EnteredAddress.ZipCode}}

Do not update, use address as entered

Choose the Account from PATH to use for this Quote:
{{Variables.AccountMatchesFiltered}} Filtered result / {{Variables.AccountMatches}} results in total

	PHLY Risk Clearance	Street	City	State	Zipcode	Fein	AccountNumber	Phone
	{{a.Name}}	{{a.Address.Line1}} {{a.Address.Line2}}	{{a.Address.City}}	{{a.Address.StateProvince}}	{{a.Address.PostalCode}}	{{a.FEIN}}	{{a.AccountNumber}}	{{a.PhoneNumber}}

Create New Path Account

Coverage Type	Limit of Liability	Retention	Premium
Directors and Officers	{{Variables.limit \| currency:"$"}}	{{Variables.selectedretention\| currency:"$"}}	{{Variables.DOPremium \| currency:"$"}}
Employment Practices	{{Variables.limit \| currency:"$"}}	{{Variables.selectedretention\| currency:"$"}}	{{Variables.EPLIPremium \| currency:"$"}}
Fiduciary	{{Variables.limit \| currency:"$"}}	{{Variables.selectedretention \| currency:"$"}}	{{Variables.FLIPremium \| currency:"$"}}

{{discount.OnlineDescription}}		{{discount.OnlineDiscount}}%	{{ Variables.Discounts \| currency:"$ "}}
Premium Subtotal			{{ Variables.SubTotal \| currency:"$ "}}
Taxes	{{Variables.StateTaxDescription}}	{{Variables.StateTaxRate*100 \| number :2}}%	{{Variables.SubTotal*Variables.StateTaxRate \| number :2 \| currency:"$"}}
Taxes	{{Variables.CityTaxDescription}}	{{Variables.CityTaxRate*100 \| number :2}}%	{{Variables.SubTotal*Variables.CityTaxRate \| currency:"$"}}

Total			{{ Variables.Total \| currency:"$"}}

Coverage Type	Limit of Liability	Retention	Premium
Directors and Officers	{{Variables.limit \| currency:"$"}}	{{Variables.selectedretention\| currency:"$"}}	{{Variables.DOPremium \| currency:"$"}}
Employment Practices	{{Variables.limit \| currency:"$"}}	{{Variables.selectedretention\| currency:"$"}}	{{Variables.EPLIPremium \| currency:"$"}}
Fiduciary	{{Variables.limit \| currency:"$"}}	{{Variables.selectedretention \| currency:"$"}}	{{Variables.FLIPremium \| currency:"$"}}

{{discount.OnlineDescription}}		{{discount.OnlineDiscount}}%	{{ Variables.Discounts \| currency:"$ "}}
Premium Subtotal			{{ Variables.SubTotal \| currency:"$ "}}
Taxes	{{Variables.StateTaxDescription}}	{{Variables.StateTaxRate*100 \| number :2}}%	{{Variables.SubTotal*Variables.StateTaxRate \| number :2 \| currency:"$"}}
Taxes	{{Variables.CityTaxDescription}}	{{Variables.CityTaxRate*100 \| number :2}}%	{{Variables.SubTotal*Variables.CityTaxRate \| currency:"$"}}

Total			{{ Variables.Total \| currency:"$"}}

{{Insurance.Description}}

{{item.Title}}

Payment Information

Billing Address

Total: $ {{Variables.Total | number:2}}

Important

Check Payment Info

$ {{Variables.Total}}

Client Info

Payment Information

Billing Address

In order to Bind Coverage you must generate a proposal
and accept the terms and conditions of the policy.

{{item.Title}}

Payment Information

Billing Address

Total: $ {{Variables.Total | number:2}}

Important

Check Payment Info

$ {{Variables.Total}}

Client Info

Payment Information

Billing Address

In order to Bind Coverage you must generate a proposal
and accept the terms and conditions of the policy.

{{SubmitConfirmation.Header}}

{{SubmitConfirmation.Body}}

{{Insurance.Description}}

{{item.Title}}

Payment Information

Billing Address

Total: $ {{Variables.Total | number:2}}

Important

Check Payment Info

$ {{Variables.Total}}

Client Info

Payment Information

Billing Address

In order to Bind Coverage you must generate a proposal and accept the terms and conditions of the policy.

{{item.Title}}

Payment Information

Billing Address

Total: $ {{Variables.Total | number:2}}

Important

Check Payment Info

$ {{Variables.Total}}

Client Info

Payment Information

Billing Address

In order to Bind Coverage you must generate a proposal and accept the terms and conditions of the policy.

{{SubmitConfirmation.Header}}

{{SubmitConfirmation.Body}}

In order to Bind Coverage you must generate a proposal
and accept the terms and conditions of the policy.

In order to Bind Coverage you must generate a proposal
and accept the terms and conditions of the policy.