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Entity & Contact Information
What 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 Number
Date Established*
MM slash DD slash YYYY
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*
MM slash DD slash YYYY
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?
MM slash DD slash YYYY
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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DO-app

Entity & Contact Information

General Information

Have any of the following occurred in the last twelve (12) months or are planned for the next eighteen (18) months?

Financial Information

Claim Information

Directors & Officers Liability Information

Recent Articles

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