Directors & Officers Insurance Quote "*" indicates required fields Step 1 of 6 16% What is your Full Name and Title* Full Legal Name of Your Entity* Business Structure*LLCSole PropPartnershipothercorpStructure if Other?* Street address* City* State* Zip code Web Address phone*email* Date Established* MM slash DD slash YYYY Detailed description of your operations* Coverage InformationD & O Limits Requested*$250,000$500,000$1,000,000$2,000,000$3,000,000$4,000,000$5,000,000Do you have a Current D & O Policy In Effect*YesNoCurrent Insurer* Current D & O Limits*None$250,000$500,000$1,000,000$2,000,000$3,000,000$4,000,000$5,000,000Current Retention/Deductible*$500$1,000$2,500$5,000$10,000$25,000$50,000Current prior & pending date* Has your insurer indicated an intent to non-renew your policy?*YesNoDo you have any subsidiaries*YesNoDo you want coverage for your subsidiaries*NAYesNo Operational InformationHave any of the following occurred in the last twelve (12) months or are planned for the next eighteen (18) months?Merger, acquisition, formation or divesting of a subsidiary*YesNoSenior management changes for reasons other than term expiration, death or retirement*YesNoLayoffs, staff reductions or facility closings*YesNoIf yes, indicate percentage of total workforce affected* Bankruptcy filing, work-out arrangements with creditors, reorganization or restructuring*YesNoDo you have any foreign operations?*YesNoIf “Yes,” indicate percentage of total revenues generated by all foreign operations* Are you a federal or state contractor?*YesNo Financial InformationWhat is the date date of your most recent annual financials MM slash DD slash YYYY Current assets*Total assets*Current Liabilities*Long term debt*Total Liabilities*Retained Earnings*Shareholder's EquityRevenues*Earnings before interest and Taxes (EBIT)*Net income*Cash flow from operations* UnderwritingHave you changed auditors in the last twelve (12) months*YesNoAre you on notice of a violation of any debt covenants*YesNoHave you ever received an adverse opinion from an auditor including but not limited to an opinion expressing doubt as to an ability to continue as a “going concern”?*YesNoHas any claim or notice of potential claim been given to any insurer for any D & O issues?*YesNoAntitrust, copyright or patent violation*YesNoDeceptive or unfair trade practices, or violation of consumer protection laws*YesNoViolation of federal or state securities laws*YesNoCriminal proceedings, investigations or actions*YesNoRegulatory or administrative actions*YesNoEmployment practices or labor related disputes*YesNoLicense revocation or suspension*YesNoOther civil, criminal or administrative proceeding*YesNo ManagementWhat is the total number of shares in the Operation?* How many Shareholders are there?* How many shares owned by officers and directors?* Have there been any changes to the Board of Directors, Management Committee or Senior Management in the past three (3) years for reasons other than term expiration, death, or retirement?*YesNoPublic offering of debt or securities?*YesNoPrivate offering of securities?*YesNoA crowdfunding offer as described in the Jumpstart Our Business Startups Act of 2012?*YesNoDo any shareholders/members own directly or beneficially ten (10) percent or more of the outstanding shares?*YesNoAre the shareholders/members either a director or officer, or have board representation?*NAYesNoIf "No" then complete the following for the 5 largest shareholdersShareholder* Percentage Owned* Shareholder Percentage Owned Shareholder Percentage Owned Shareholder Percentage Owned Shareholder Percentage Owned Do you have an in-force policy covering cyber risks, network security and privacy?*YesNoIf “Yes,” and you have a current cyber policy please provide name of insurer and current limits of liability* No person or entity proposed for coverage has knowledge of any fact, circumstance, situation, transaction or event, which he or she has reason to believe, could give rise to a claim for which coverage would be requested under a policy issued to this entity*TrueFalseIf "False" then please explain.*What date do you need the coverage to start?* MM slash DD slash YYYY We will need the following in order to approve coverage. Please upload the following documents:1) A most recent year-end audited or CPA prepared financial statement. If more than six (6) months old, please attach most recent company prepared interim financial statements as well. 2) List all shareholders, indicating percentage owned and which are directors, officers or employees of entity. 3) List directors and officers of Named Applicant and identify any outside directorships or officerships, if applicable.Accepted file types: pdf, doc, docx, Max. file size: 100 MB. Δ
