Tech Errors and Omissions 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 In the 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 List the industries in which the company operates or sells technology products/services. (Percentages must total 100%.) * Does the company use a standard written agreement with all customers? * Yes No Are all customer agreements reviewed by Legal Counsel before execution? * Yes No Is the applicant a Community Association? * Yes No Is Technology Errors & Omissions coverage required by customer contracts? * Yes No Which of the following provisions in the company’s favor are included in standard agreements? Check all that apply. * Limitation of liability clause Hold harmless clause Indemnification clause Exclusion of consequential damages Mandatory or binding arbitration Other protective clauses 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 What percentage of customer agreements are standard form vs. manuscript? (Best estimate.) * 0-25% 26-50% 51-75% 76-100% 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.
