Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Primary Contact *

First Name

Last Name

HR Contact *

First Name

Last Name

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

Which of the following plans does the company sponsor? (Check all that apply) *

Defined Contribution Plan (e.g., 401(k), Profit Sharing)

Health & Welfare Plan (e.g., Medical, Dental, Vision)

Defined Benefit Plan (e.g., Pension, Money Purchase)

Employee Stock Ownership Plan (ESOP) (not the same as employee stock option plan)

Has any fiduciary of the company ever: (Check all that apply) *

Been accused, found guilty, or held liable for a breach of trust?

Been convicted of criminal conduct?

Been assessed fees, fines, or penalties under an IRS, DOL, or other government authority voluntary compliance or settlement program?

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

Prior knowledge of any facts/circumstances that could reasonably give rise to a claim? *

Yes

No