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2020 E&O Application

2020 E&O Application

All questions must be answered completely. If any questions are considered "not applicable", please explain why. This application must be signed and dated by a principal of the firm.

NOTE: This application is for a "claims made" insurance policy.

Person Completing Form

First Name
Last Name

Section I. Applicant Information

Section II. Policy History

Please provide current policy information:

Please indicate requested:

Section III. Professional Services

Percentage (%) of Revenues by Service Type

Describe the services the Named Insured and any Subsidiaries provides. If none, please enter "0".

Section III. Percentages

Total should equal 100%.

Section III. Professional Services

Total revenue percentage is GREATER than 100%. Please update your entries.

Total revenue percentage is LESS than 100%. Please update your entries.


Please tell us about your Valuation Services for Publicly Traded Companies. Do you offer:


Please tell us about your M&A Services. Do you offer:


Your Team and Contracts

3(b). Does the Applicant's contracts contain any of the following:

4. Are you or any of your staff currently members of any of the following professional organizations? Check all that apply.

6. How do you obtain real estate appraisals?

IV. Prior Activities Information

Other Information

1. The undersigned declares that to the best of his/her knowledge the statements herein are true. Signing of this Application does not bind the undersigned to complete the insurance, but it is agreed that this Application shall be the basis of the contract should a Policy be issued, and this application will be attached to and become a part of such Policy, if issued. The Insurer hereby is authorized to make any investigation and inquiry in connection with this Application as they may deem necessary.

2. It is represented that the particulars and statements contained in the Application for the proposed Policy and any materials submitted herewith (which shall be retained on files by Insurer and which shall be deemed attached hereto, as if physically attached hereto), are the basis for the proposed Policy and are to be considered as incorporated into and constituting a part of the proposed Policy.

3. It is agreed that in the event there is any material change in the answers to the questions contained herein prior to the effective date of the Policy, the Applicant will notify the Insurer and, at the sole discretion of Insurer, any outstanding quotations or binders may be modified or withdrawn.

4. It is agreed that in the event of any misstatement, omission, or untruth in this Application or any material submitted along with or contained herein, the Insurer has the right to exclude from coverage any claim based upon, arising out of, attributable to, directly or indirectly resulting from, in consequence of, or in any way involving such misstatement, omission or untruth.

Signature


For purposes of creating a binding contract of insurance by this application or in determining the rights and obligations under such contract in any court of law, the parties acknowledge that a signature reproduced by either digital signature, electronic signature, facsimile or photocopy shall have the same force and effect as an original signature and that the original and any such copies shall be deemed one and the same document. This application is provided under the Uniform Electronic Transactions Act – Col. Rev. Stat. §§ 24-71.3-101 et seq. By submitting this application, you are confirming your agreement to submit this application electronically, and your indication of agreement, along with information provided, will have the same force and affect as if this application was submitted manually and your manual signature was provided. You should retain a copy of this application for your records. (A copy of the completed application will be emailed to you at the email provided above shortly after submission. )

This application must be signed by an Executive Officer of the Applicant.

*Required Field.

Sending