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Intellectual Property Insurance Quote Request

Intellectual Property Insurance Quote Request

Submit your intellectual Property Insurance Quote Request here, we will secure you terms as quickly as possible

Company Full Legal name(Required)

Who is your company's contact for this coverage?(Required)

First Last

What is Their Position?(Required)

Contact Email Address(Required)

Contact Phone Number(Required)

What is your primary business address?(Required)

Street Address City State / Province / Region ZIP / Postal Code

What Date Was the Company Established(Required)

MM slash DD slash YYYY

Website_address

How many employees does the company have?(Required)

What is the company owner's or CEO's name?(Required)

First Last

Financial_year_end(Required)

MM slash DD slash YYYY

Product Details

Domestic Sales

Last Year's Gross Sales(Required)

Current Year Est. Gross(Required)

Next Year Est. Gross(Required)

Canada Sales

Last Year's Gross Sales

Current Year Est. Gross

Next Year Est. Gross

Europe Sales

Last Year's Gross Sales

Current Year Est. Gross

Next Year Est. Gross

Asia Sales

Last Year's Gross Sales

Current Year Est. Gross

Next Year Est. Gross

Africa and Latin/South America Sales

Last Year's Gross Sales

Current Year Est. Gross

Next Year Est. Gross

Australia and New Zealand Sales

Last Year's Gross Sales

Current Year Est. Gross

Next Year Est. Gross

Please state what percentage of your total revenue relates to the sale of products (%):

Please state whether there has been, or it is anticipated there will be, any merger, acquisition or joint venture(Required)

Yes

No

Please describe below the products and services supplied by your business, including how your products and services differ from your competitors(Required)

Please provide details of your top 5 income generating products

Product(Required)

Description(Required)

Revenue(Required)

Product

Description

Revenue

Product

Description

Revenue

Product

Description

Revenue

Product

Description

Revenue

Please provide details of your top 3 competitors

Competitor Name

Domicile Country

Est Revenue

Competitor Name

Domicile Country

Est Revenue

Competitor Name

Domicile Country

Est Revenue

Please state whether you intend to introduce any new product, or market an existing product in a new business sector or territory, during the next 12 months:(Required)

Yes

No

If ‘yes’, please provide details including the income that you anticipate generating:(Required)

Are any products sold under a third party’s name or brand name?(Required)

Yes

No

If ‘yes’, please provide details, including the amount of revenue generated from each product sold under a third party’s name or brand name:(Required)

What types of intellectual properties do you own and are looking to protect?

Patents

Registered Designs

Registered Trade or Service Marks

Indicate if these contracts impose any obligation on you to indemnify or hold harmless this client in the defense of any infringement proceedings?

Registered Patents

Title or Brand name

Territory

Patent/Application #

Patent/Application Date

MM slash DD slash YYYY

What is this Patents status?

Identifying Title or Brand name

Territory

Patent/Application #

Patent/Application Date

MM slash DD slash YYYY

What is this Patents status?

Identifying Title or Brand name

Territory

Patent/Application #

Patent/Application Date

MM slash DD slash YYYY

What is this Patents status?

Identifying Title or Brand name

Territory

Patent/Application #

Patent/Application Date

MM slash DD slash YYYY

What is this Patents status?

Identifying Title or Brand name

Territory

Patent/Application #

Patent/Application Date

MM slash DD slash YYYY

What is this Patents status?

Identifying Title or Brand name

Territory

Patent/Application #

Patent/Application Date

MM slash DD slash YYYY

What is this Patents status?

Registered Designs

Title or Brand name

Territory

Application/Grant#

Application/Grant Date

Status

Title or Brand name

Territory

Grant/Application #

Grant/Application Date

MM slash DD slash YYYY

Status

Title or Brand name

Territory

Grant/Application #

Grant/Application Date

MM slash DD slash YYYY

Status

Title or Brand name

Territory

Grant/Application #

Grant/Application Date

MM slash DD slash YYYY

Status

Title or Brand name

Territory

Grant/Application #

Grant/Application Date

MM slash DD slash YYYY

Status

Title or Brand name

Territory

Grant/Application #

Grant/Application Date

MM slash DD slash YYYY

Status

Registered Trade or Service Marks

Registered Mark

Territory

Grant/Application #

Class(es)

Grant/Application Date

MM slash DD slash YYYY

Status

Registered Mark

Territory

Grant/Application #

Class(es)

Grant/Application Date

MM slash DD slash YYYY

Status

Registered Mark

Territory

Grant/Application #

Class(es)

Grant/Application Date

MM slash DD slash YYYY

Status

Registered Mark

Territory

Grant/Application #

Class(es)

Grant/Application Date

MM slash DD slash YYYY

Status

Registered Mark

Territory

Grant/Application #

Class(es)

Grant/Application Date

MM slash DD slash YYYY

Status

Registered Mark

Territory

Grant/Application #

Class(es)

Grant/Application Date

MM slash DD slash YYYY

Status

Other Intellectual properties

Any other intellectual property, such as unregistered trademarks, copyrights, trade secrets or domain names

Do you own or are you the exclusive licensee of the intellectual property?(Required)

Yes

No

If no, please detail any joint ownership or provide further information about the third party owners of the intellectual property(Required)

Please complete the following in respect of your current three largest contracts

Indicate if these contracts impose any obligation on you to indemnify or hold harmless this client in the defense of any infringement proceedings?

Client Name?

Contract Income

Duration of Contract

Hold harmless?

Yes

No

Client Name?

Contract Income

Duration of Contract

Hold harmless?

Choice2

No

Client Name?

Contract Income

Duration of Contract

Hold harmless?

Choice4

No

Do you have any other contract that requires you to indemnify or hold harmless any other third parties?

Yes

No

Please describe below your procedure for preventing infringing on third party intellectual property rights;(Required)

Please describe below your procedure for obtaining licenses to use and the monitoring of third party intellectual property rights(Required)

Please describe your procedures for managing intellectual property right issues, including responding to an allegation of infringement and how the individual responsible for intellectual property rights issues is qualified for the role:(Required)

Defensive Actions

In respect of intellectual property, please state whether you have ever

defended or faced an action brought by a third party in respect of actual or alleged intellectual property infringement, or other allegations in respect of misuse of intellectual property including trade secrets

Yes

No

received cease and desist correspondence, or other correspondence warning you in respect of actual or alleged infringement of intellectual property:

Yes

No

received any opposition, challenge objection or observation concerning the validity of intellectual property rights

Yes

No

received any correspondence or action concerning the ownership of intellectual property rights

Yes

No

received correspondence in respect of an actual or alleged breach of a confidentiality undertaking, license agreement or other contractual obligation in respect of intellectual property

Yes

No

received an intellectual property rights license fee request

Yes

No

commenced proceedings against a third party in respect of actual or alleged infringement of intellectual property, or other allegations in respect of misuse of intellectual property including trade secrets

Yes

No

sent a cease and desist correspondence, or other correspondence warning a third party in respect of actual or alleged infringement of intellectual property

Yes

No

sent any opposition, challenge, objection or observation concerning the validity of intellectual property rights

Yes

No

sent any correspondence or action concerning the ownership of intellectual property rights

Yes

No

sent correspondence in respect of an actual or alleged breach of a confidentiality undertaking, license agreement or other contractual obligation in respect of intellectual property

Yes

No

sent an intellectual property rights license fee request

No

Yes

If you have answered ‘yes’ to any of the above questions, please provide full details comprising: (i) the opposing legal entity; (ii) the date the matter commenced (iii) the date the matter was resolved or latest circumstances; (iv) the total legal costs incurred by you in the matter (v) the total compensation paid to the opposing legal entity in the form of settlement payment or damages, if relevant (vi) the intellectual property alleged to have been infringed or disputed:

Have you ever had an application or renewal for intellectual property infringement insurance declined by an insurer or been subject to any special terms or conditions(Required)

Yes

No

If so, explain.

had any insurance cancelled or voided(Required)

Yes

No

If so, please provide details on why and when.(Required)

Please indicate the required coverage by ticking the appropriate boxes below(Required)

Patent Defense

All other intellectual property defense

Patent pursuit

All other IP Pursuit

Please indicate the required limit of liability by ticking the appropriate box below(Required)

$250,000

$500,000

$1,000,000

$2,000,000

$5,000,000

other

Liability Limit Other(Required)

What deductible would you prefer?

$1,000, $2,500, $5,000, $10,000, $25,000, $50,000, $100,000?

Please indicate the territorial limits where cover is to be provided by ticking the appropriate box below

Your Country of Domicile

Other

Worldwide

Other_territory(Required)

Claims Experience

Please state whether you are aware of any incident:

which may result in a claim under any of the insurance for which you are applying to purchase in this application form(Required)

Yes

No

which resulted in legal action being made against any of the companies to be insured within the last 5 years

Yes

No

which resulted in a partner or director being found guilty of any criminal, dishonest or fraudulent activity or been investigated by any regulatory body

Yes

No

Please provide details on any claim info you have alluded to above(Required)

Please provide any Additional Information that you may feel is pertinent to this inquiry

What date are you looking to have coverage start?(Required)

MM slash DD slash YYYY

Signature1

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Risk Strategies – Castle Rock Capacity Insurance ©2006
750 Third Ave, Suite 1500
New York, NY 10017
V: 212.360.2334 F:929.332.7938

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