E & O Application

E and 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

Firm Name

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".

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 M&A Services. Do you offer:







Please tell us about your Valuation Services for Publicly Traded Companies. 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 members of any of the following professional organizations? Check all that apply.

6. How do you obtain real estate appraisals?

IV. Prior Activities Information

V. Data Breach Insurance Application Warranty Statement

In signing this Statement, the Applicant confirms that it:

1. has a written corporate-wide privacy policy which addresses information management, records and compliance and conducts awareness training regarding Privacy issues for all employees;

2. maintains the following on it’s computer system and regularly updates:
i) firewalls including for use of mobile laptops and PCs remotely.
ii) anti-virus and malware prevention solutions.
iii) a formalized strategy to ensure timely updates of software and operating systems;

3. does not collect, process and store more than 100,000 individual records that can be considered to be personally identifiable information. Personally identifiable information means any information collected that could be used to identify an individual;

4. has established and documented system backup and recovery procedures;

5. backs-up all sensitive/critical business data at least every 7 days;

6. has a written Business Continuity and Disaster Recovery Plan in place which establishes the steps for keeping all aspects of the business functioning and IT related infrastructure recovery/continuity in the midst of disruptive events.

This Declaration, including the representations and warranties overleaf, must be signed by a person who has the authority to sign on behalf of and to bind the Applicant, including all entities and individuals seeking insurance through this Application.

Data Breach Insurance Application Warranty Statement

In signing this Statement, the Applicant hereby warrants and represents that:

i) It has not been declined for errors and omissions, privacy, cyber or media liability insurance or had an existing policy cancelled or non-renewed.

ii) It is not aware of any computer or information security incidents during the past three years. An incident includes any unauthorized access, intrusion, breach, compromise or use of your computer systems including embezzlement, fraud, theft of proprietary information, denial of service, electronic vandalism or sabotage, computer virus, regulatory investigations or other similar incidents including regulatory investigations that could give rise to a claim that may have been covered by this policy.

iii) At the time of signing this Application the Applicant, apart from as disclosed herein, has no reason to believe that a claim may be made against it for any act, error or omission on the part of any principal, partner, director, officer or employee of the Applicant or its predecessors in business.

iv) The above particulars and statements and the information contained in any attachments to this Application together with any additional information provided in support of this Application, which by reference are made a part hereof, are true and complete and that no material facts have been omitted or misstated.

The Applicant acknowledges that Underwriters rely on this Application and its attachments and any additional supporting information provided as the material basis of any contract of insurance that may be entered into between the Applicant and Underwriters. The Applicant further acknowledges that the furnishing of this Application does not bind Underwriters to provide insurance cover and that a binding contract of insurance is not in place unless an offer of insurance is made and having been accepted by the Applicant is also accepted by Underwriters.

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. In the event this application is submitted electronically, 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

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