For Brokers
For Companies
Coverage
Contract Frustration
Directors & Officers
Employment Practices Liability
Influencer & Content Creator Insurance
About
Careers
Contact
For Brokers
For Companies
Coverage
Contract Frustration
Directors & Officers
Employment Practices Liability
Influencer & Content Creator Insurance
About
Careers
Contact
For Brokers
For Companies
Coverage
Contract Frustration
Directors & Officers
Employment Practices Liability
Influencer & Content Creator Insurance
About
Careers
Contact
Management Liability Application
Applicant (legal name of company):
*
Website
*
Mailing Address
*
Does the company have any other locations?
*
Corporate Structure (pick one)
*
Corporation
LLC
Sole Proprietorship
Joint Venture
Other
Non-Profit
If Other, please give us details:
Operations Descriptions
*
Incorporation State
*
Incorporation Date
*
MM slash DD slash YYYY
Subsidiaries details
Overseas Rev
*
D&O limit
D&O retention
D&O inception
EPL limit
EPL retention
EPL inception
EPL sup limit
EPL sup retention
EPL sup inception
EPL Wage limit
EPL Wage retention
EPL Wage inception
Key Person inception
Key Person limit
Key Person retention
D&O Carrier
D&O Premium
D&O Expiration Date
MM slash DD slash YYYY
D&O Litigation Date
MM slash DD slash YYYY
D&O Limit
EPL Carrier
EPL Premium
EPL Expiration Date
MM slash DD slash YYYY
EPL Litigation Date
MM slash DD slash YYYY
EPL Limit
KP Carrier
KP Premium
KP Expiration Date
MM slash DD slash YYYY
KP Litigation Date
MM slash DD slash YYYY
KP Limit
Limit Structure
*
Separate
Shared
N/A
merger & acqusition details 18 months
merger & acqusition details next 12 months
management liability claim in past 3 years details
denied D&O, EPLI or KP before
Yes Quesitons.2.0
*
Yes
No
Yes Quesitons.2.0
*
Yes
No
Yes Quesitons.2.0
*
Yes
No
Yes Quesitons.2.0
*
Yes
No
Yes Quesitons.2.0
*
First Choice
Second Choice
Third Choice
Yes Quesitons.2.0
*
Yes
No
Yes Quesitons.2.0
*
Yes
No
Yes Quesitons.2.0
*
Yes
No
Financial Prep
*
Financial Prep
Financial Prep
Financial Prep
Financial Prep
Total Assets
Current Assets
Total Liabilities
Current Liabilities
Total Revenues
Net Income or Loss
Long Term Liabilities over 75%
Long term liabilities 50% 18 months details
Current Liabilities Details
Yes Quesitons.2.0
*
Yes
No
Yes Quesitons.2.0
*
Yes
No
Yes Quesitons.3.0
*
Yes
No
Yes Quesitons.3.0
*
Yes
No
Legal or Financial restructuring details
securities & votings rights - entity details
securities & votings rights - not former director details
Private securitites details
M&A activity details
Other direct sales details
social networking or crowdfunding details
SEC filings links
location closure details
debt covenant details
reorganization with creditors details
public sale of securities details
parent company details
Share ownership D&O
*
Shareholder 1 - Name
Shareholder 1 - Shares
Shareholder 1 - Class
Board Representation
*
Yes
No
Board Representation
*
Yes
No
Shareholder 2 - Name
Shareholder 2 - Shares
Shareholder 2 - Class
Shareholder 3 - Name
Shareholder 3 - Shares
Shareholder 3 - Class
Shareholder 4 - Name
Shareholder 4 - Shares
Shareholder 4 - Class
stock or ERISA details
change to board or senior mgmt details
outstandin director loans details
bankruptcy details
Funding Scenarios
*
You currently have enough funding secured to maintain operations for the next 12 - 18 months
You currently do not have enough funding secured to maintain operations for the next 12 - 18 months, but current investors have agreed to fund operations for the next 12 - 18 months.
You currently do not have enough funding secured to maintain operations for the next 12 - 18 months, but there are plans to raise additional capital in order to maintain operations for the next 12 - 18 months. Please provide details.
You currently do not have enough funding secured to maintain operations for the next 12 - 18 months and there are no plans to raise additional capital from current investors or additional rounds of funding.
additional capital details
services for a fee details
earn out obligation details
act as parter or manager details
FDA approval details
TCPA details
insurance operations details
entertainment content details
government revenue 10% details
Total number current yearFull Time
*
Total number previous yearFull Time
*
Total number current yearPart time including seasonal andor volunteers
*
Total number previous yearPart time including seasonal andor volunteers
*
Total number current yearIndependent Contractors
*
Total number previous yearIndependent Contractors
*
Total number current yearLeased Employees
*
Total number previous yearLeased Employees
*
state employee locations details
Remuneration of employees
*
outside US employee locations details
Remuneration of employees 100k+
*
25% left company 18 months details
25% left company 18 months details
Terminations Review
*
Human Resources
In-house Counsel
Outside Counsel
None
lawsuits, charges against applicant
actions that give rise to a claim
knowledge of inquiry or investigation
knowledge of claims
Date of Signature
*
MM slash DD slash YYYY
Name of Signature
*
Title of Signature
*
CAPTCHA
Δ
