CRSM Online Application

Thank you very much for applying for General/Professional Liability as a CRSM member benefit.

Please note all members may not be eligible for this coverage. 

Once your application has been completed and returned it will be submitted to an underwriter for review. Please take a moment to review the following description of operations listed hereunder which are used in determining primary eligibility for this program. If you have questions concerning whether your business practices meet these requirements please contact David Vaughan Jr. at (918) 779-7884 or 
dlvjr@higginbotham.net.

Regulatory Compliance Consulting and Clinical or Site Management Organization: Strategic Planning-Recruitment and Assembly, Trial Management, Trial Monitoring, Data Management, Analysis and Reporting, Protocol Preparation and Facilities Assessment. All Consulting Professional Services provided are required to comply with all laws and regulations at a local, state and federal government level in accordance with any and all Federal Regulatory Compliance requirements.

If it is determined that your work is outside the acceptable criteria for this program, please be assured that we will make every effort to obtain the very best coverage at the most affordable price with an alternate insurance provider. Please note that subcontractors are not covered under this policy

Once your application has been approved by the company you will be notified via email from Vaughan Insurance Group. Attached to this notification will be an invoice for the annual premium. As soon as payment has been received, you will be provided a policy binder for 60 days indicating your coverage has been bound pending receipt of your policy from the insurance company. Also, any certificate of insurance requests will be sent at this time.

To apply for General/Professional Liability please complete and submit the form below.

Coverage not available under this particular program in the following states, however, we can look at alternative coverage options for you.
  • AK
  • CA
  • DC
  • DE
  • HI
  • LA
  • NY
  • VT
  • WA

CRSM: Clinical Research Site Management

FOR MEMBERS applying for General/Professional Liability as a CRSM member benefit through THEIR association.


*Please note that "Prior Acts" coverage is only available when your expiring policy is written on on a "claims made" form directly prior to purchasing this coverage. Coverage for "Prior Acts" will be provided for a (2) year term for a one time premium charge of 25% of the annual premium

Applicant Information Section
















For "Other" please specify above.



ADDITIONAL INFORMATION







LOSS HISTORY




Claim Date Claim Description Amount Paid
Claim 1
Claim 2
Claim 3
Claim 4
Claim 5

Claim Date Claim Description Amount Paid
Claim 1
Claim 2
Claim 3
Claim 4
Claim 5

CURRENT COVERAGES


Insurance Company Effective Coverage Date Policy#
Commercial General Liability Policy Info

Insurance Company Effective Coverage Date Policy#
Commercial Auto Policy Info

Insurance Company Effective Coverage Date Policy#
Workers Comp Policy Info

Insurance Company Effective Coverage Date Policy#
Excess /Umbrella Policy Info

COVERAGE ELIGIBILITY REQUIREMENTS


NOTE: All of the below questions must be answered "Yes" to be eligible for coverage.







Anticipated # Trial Sites Annually Anticipated # of Trials Annually Are Subjects Required to Stay Overnight?
Provide Details Here
Financing options are available upon request.

Thank you for allowing us to service your insurance needs. It has been a pleasure serving you. Should you have any additional questions, please contact David Vaughan Jr. at (918) 779-7884 or dlvjr@higginbotham.net.

* INFORMATION CONTAINED HEREIN TO THE BEST OF MY KNOWLEDGE IS ACCURATE AND COMPLETE