DO-app Entity & Contact InformationWhat is your full name?*What is your title in the organization?*Legal Name of Entity*Legal Type of Entity* LLC Sole Proprietorship Partnership Corporation Other Type of Entity if Other*Street Address*City*State*Zip*Web Address Detailed Description of your Operations*email* Contact Phone NumberDate Established* MM slash DD slash YYYY General InformationDo you have any subsidiaries?* Yes No Do you want coverage for the subsidiaries?* NA Yes No Do you have a Current D & O Policy In Effect?* Yes No Current D & O Insurance Provider (Not Broker)*Current D & O Limits*None$100,000$250,000$500,000$1,000,000$2,000,000$3,000,000$4,000,000$5,000,000Current D & O Retention*$500$1,000$2,500$5,000$10,000$25,000$50,000Current D & O prior and pending date* MM slash DD slash YYYY Has the insurer above indicated an intent to non-renew?* Yes No What D& O Limits Are you Requesting?*$100,000$250,000$500,000$1,000,000$2,000,000$3,000,000$4,000,000$5,000,000Have 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* Yes No Senior management changes for reasons other than term expiration, death or retirement* Yes No Layoffs, staff reductions or facility closings* Yes No If yes, percentage of total workforce affected by layoffs*Bankruptcy filing, work-out arrangements with creditors, reorganization or restructuring* Yes No Do you have any foreign operations?* Yes No If yes, indicate percentage of total revenues generated by all foreign operations*Is your operation a federal or state contractor?* Yes No Financial InformationWhat is your most recent year end financial date? MM slash DD slash YYYY Current assetsTotal assetsCurrent LiabilitiesLong term debtTotal LiabilitiesRetained EarningsShareholder's EquityRevenuesEarnings before interest & Taxes (EBIT)Net incomeCash flow from operationsHave you changed auditors in the last twelve (12) months?* Yes No Are you on notice of a violation of any debt covenants* Yes No Have 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”?* Yes No Claim InformationHas any claim or notice of potential claim been given to any insurer for D & O issued?* Yes No Criminal proceedings, investigations or actions* Yes No Antitrust, copyright or patent violation* Yes No Deceptive or unfair trade practices, or violation of consumer protection laws* Yes No Violation of federal or state securities laws* Yes No Regulatory or administrative actions* Yes No Employment practices or labor related disputes* Yes No License revocation or suspension* Yes No Other civil, criminal or administrative proceeding* Yes No Directors & Officers Liability InformationTotal number of shares/units outstandingTotal number of shareholders*Total number 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?* Yes No Public offering of debt or securities?* Yes No Private offering of securities?* Yes No A crowdfunding offer as described in the Jumpstart Our Business Startups Act of 2012?* Yes No Do any shareholders/members own directly or beneficially ten (10) percent or more of the outstanding shares?* Yes No Are the shareholders/members either a director or officer, or have board representation? NA Yes No VI 5 Shareholder 1VI 5 Percentage owned 1VI 5 Shareholder 2VI 5 Percentage owned 2VI 5 Shareholder 3VI 5 Percentage owned 3VI 5 Shareholder 4VI 5 Percentage owned 4VI 5 Shareholder 5VI 5 Percentage owned 5Do you have an in-force policy covering cyber risks, network security and privacy?* Yes No If “Yes,” please provide name of cyber 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 Named Applicant* True False If there are exceptions to the above, please provide details*This field is hidden when viewing the formapp date