Directors and Officers (D&O) Insurance Application Company Name * Website * http:// Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Primary Contact * First Name Last Name Email * HR Contact * First Name Last Name Email * How many full-time employees do you have? * How many part-time? * How many contractors or seasonal? * How many employees or contractors are in California? * Have there been any leadership changes in last 3 years (other than retirement/death)? * Yes No n past 12 months, any closures/mergers/consolidations causing 20%+ layoffs (or planned)? * Yes No Public offerings or private placements in last 24 months (or planned)? * Yes No Reorganization/arrangement with creditors in last 24 months (or planned)? * Yes No Mergers, acquisitions, or divestitures in last 24 months (or planned)? * Yes No Has there been a debt covenant default in last 12 months (or anticipated)? * Yes No Does the company have debt (e.g., LOC, convertible notes)? * Yes No Litigation in last 5 years (IP/antitrust/civil/criminal/administrative)? * Yes No Any current SEC or IRS investigation/request for information? * Yes No Any related-party transactions (per GAAP)? * Yes No Is the applicant a Community Association? * Yes No Do you have existing Directors & Officers (D&O) coverage? * Yes No Do you have existing Employment Practices Liability (EPL) coverage? * Yes No Do you have existing Fiduciary Liability coverage? * Yes No Do you have existing Cyber Liability coverage? * Yes No Do you have existing Tech Errors & Omissions (E&O) coverage? * Yes No Total Revenue (most recent FY end) * $ Total Assets (most recent FY end) * $ Total Liabilities (most recent FY end) * $ Net Income (most recent FY end) * $ Total Cash (most recent FY end) * $ Prior knowledge of any facts/circumstances that could reasonably give rise to a claim? * Yes No Thank you - your application has been submitted. An Execurisk broker will contact you within 24 hours. In the meanwhile, please send your financial documents to docs@execurisk.com.
