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* LLC Sole Prop Partnership other corp Structure if Other?*Street address*City*State*Zip codeWeb Addressphone*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* Yes No Current 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?* Yes No Do you have any subsidiaries* Yes No Do you want coverage for your subsidiaries* NA Yes No 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* 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, indicate percentage of total workforce affected*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*Are you a federal or state contractor?* Yes No 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* 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 Has any claim or notice of potential claim been given to any insurer for any D & O issues?* 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 Criminal proceedings, investigations or actions* 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 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?* 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 If "No" then complete the following for the 5 largest shareholdersShareholder*Percentage Owned*ShareholderPercentage OwnedShareholderPercentage OwnedShareholderPercentage OwnedShareholderPercentage OwnedDo you have an in-force policy covering cyber risks, network security and privacy?* Yes No If “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* True False If "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: 6 GB.
