CRPC Online Application

Thank you very much for applying for General/Professional Liability through your association as a CRPC 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 please contact Ty Rainey at (918) 794-3884 or ty@vaughanins.com.

Regulatory Compliance Consulting for Clinical Trial Operation: Clinical Monitoring, Auditing, Medical Writing in Accordance with Approved Practices and Guidelines set forth by the FDA, Regulatory Compliance, Data Management, Statistical Management, Quality Assurance, Validation, FDA Regulated Strategies and Standard Operating Procedures Monitoring. 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.

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.

CRPC: Clinical Research Professional Consultant

FOR MEMBERS applying for General/Professional Liability as a CRPC 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 below.
  • ADDITIONAL INFORMATION
    If "yes,"please explain below.
  • Loss History

    If "Yes" please explain below
    If "yes" please enter all occurrences, reserves or claims for the prior 5 years.
  • Claim DateClaim DescriptionAmount Paid 
    Add a new row
    To add more entries, click on the + sign at end of row #1
  • Current Coverages

    If "Yes" please fill in spaces below.
  • Insurance Co.Effective Coverage DatePolicy# 
    Add a new row
    To add more entries, click on the + sign at end of row #1
    If "Yes" please fill in spaces below.
  • Insurance Co.Effective Coverage DatePolicy# 
    Add a new row
    To add more entries, click on the + sign at end of row #1
    If "Yes" please fill in spaces below.
  • Insurance Co.Effective Coverage DatePolicy# 
    Add a new row
    To add more entries, click on the + sign at end of row #1
    If "Yes" please fill in spaces below.
  • Insurance Co.Effective Coverage DatePolicy# 
    Add a new row
    To add more entries, click on the + sign at end of row #1
  • Pricing & Premium Determination

  • Please enter information below to calculate estimated costs.
  • Please add the number of people meeting this designation. A Decision Maker is defined as "any Employee that is not Clerical, Accounting or Sales” List up to 5 additional Decision Makers here. For more than 5, please contact us.
  • $0.00
    Total of Primary Limit + Excess Liability + Additional Decision Makers
    If "Yes" coverage will not be bound
  • Payment Options

    Premium financing arranged through Premium Finance Specialist with 25% down payment and 9 equal installments
  • Please remit payments to:

    Vaughan Insurance Group, LLC
    P.O. Box 52534
    Tulsa, Ok 74152

    Thank you for allowing Vaughan Insurance Group to service your insurance needs. It has been a pleasure serving you. Should you have any additional questions, please contact Ty Rainey at (918) 794-3884 or ty@vaughanins.com.

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

  • This field is for validation purposes and should be left unchanged.

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