DO-app

Entity & Contact Information

What is your full name?*

What is your title in the organization?*

Legal Name of Entity*

Legal Type of Entity*

Type of Entity if Other*

Street Address*

City*

State*

Zip*

Web Address

Detailed Description of your Operations*

email*

Contact Phone Number

Date Established*

General Information

Do 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*

Current D & O Retention*

Current D & O prior and pending date*

Has the insurer above indicated an intent to non-renew?*

Yes
No

What D& O Limits Are you Requesting?*

Have 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 Information

What is your most recent year end financial date?

Current assets

Total assets

Current Liabilities

Long term debt

Total Liabilities

Retained Earnings

Shareholder's Equity

Revenues

Earnings before interest & Taxes (EBIT)

Net income

Cash flow from operations

Have 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 Information

Has 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 Information

Total number of shares/units outstanding

Total 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 1

VI 5 Percentage owned 1

VI 5 Shareholder 2

VI 5 Percentage owned 2

VI 5 Shareholder 3

VI 5 Percentage owned 3

VI 5 Shareholder 4

VI 5 Percentage owned 4

VI 5 Shareholder 5

VI 5 Percentage owned 5

Do 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*

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