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Medical Travel Insurance
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Business Owner’s Policy
Intellectual Property
Product Liability
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Property Insurance
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Employment Practices & Liability
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Nursing
Property Management
Architects & Engineers
Fitness & Wellness
Healthcare
CPA
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Forms
Commercial – Employer’s Practices & Liability Application
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Commercial - Employer's Practices & Liability Application
CLIENT INFORMATION
Name of Applicant
*
First
Last
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
What type of business is this?
*
For Profit
Not For Profit
North American Industry Classification System Code (NAICS):
Nature of Operations:
*
Website:
Has the Applicant been in business longer than three (3) years?
Yes
No
Is the Applicant a publicly-held or a public reporting company under the Securities Exchange Act of 1934, as amended?
Yes
No
Has the Applicant been involved with, negotiated, attempted or transacted any merger, acquisition, asset sale or divestment in the past eighteen (18) months where such merger, acquisition, asset sale or divestment involved more than twenty five percent (25%) of the total assets or securities of the Applicant?
Yes
No
If "yes", please provide details.
Does the Applicant contemplate transacting any merger, acquisition, asset sale or divestment in the next twelve (12) months where such merger, acquisition, asset sale or divestment would involve more than fifty percent (50%) of the total assets or securities of the Applicant?
Yes
No
If "yes", please provide details.
FINANCIAL INFORMATION
Describe the following financial information of the Applicant for the most recent fiscal year-end.
Total Assets
Gross Revenues
Net Income
Net Loss
Cash flow from operating activities
Do the current liabilities exceed current assets?
Yes
No
If "yes", please provide details.
Do long-term liabilities exceed seventy five percent (75%) of total assets?
Yes
No
If "yes", please provide details.
Will more than fifty percent (50%) of the total long-term liabilities mature within the next eighteen (18) months?
Yes
No
If "yes", please provide details.
Is the Applicant currently in default or anticipate in the next twelve (12) months to be in default of any debt covenants?
Yes
No
If "yes", please provide details.
Does the Applicant anticipate in the next twelve (12) months or has the Applicant transacted in the last twenty four (24) months any restructuring or legal or financial reorganization or filing for corporate bankruptcy?
Yes
No
If "yes", please provide details.
Does any person or entity who owns or controls fifty percent (50%) or more of the outstanding securities of the Applicant anticipate in the next twelve (12) months filing for or has any such person or entity within in the last twenty four (24) months filed for personal or corporate bankruptcy?
Yes
No
If "yes", please provide details.
Does the Applicant have any actual or potential earn-out or other contingent payment obligation in the next twenty four (24) months to any person or entity where such payment obligation exceeds $500,000?
Yes
No
If "yes", please provide details.
PRIOR INSURANCE INFORMATION
Describe any current insurance maintained.
If you have coverage for EMPLOYMENT PRACTICES, please fill out the following:
Name of current insurer and date first purchased:
Limit of Liability:
Retention:
Premium:
Expiration Date:
If you have coverage for DIRECTORS and OFFICERS, please fill out the following:
Name of current insurer and date first purchased:
Limit of Liability:
Retention:
Premium:
Expiration Date:
If you have coverage for FIDUCIARY, please fill out the following:
Name of current insurer and date first purchased:
Limit of Liability:
Retention:
Premium:
Expiration Date:
If you have coverage for COMMERCIAL CRIME, please fill out the following:
Name of current insurer and date first purchased:
Limit of Liability:
Retention:
Premium:
Expiration Date:
If you have coverage for PRIVACY/PRIVACY BREACH, please fill out the following:
Name of current insurer and date first purchased:
Limit of Liability:
Retention:
Premium:
Expiration Date:
If you have coverage for TECHNOLOGY ERRORS & OMISSIONS, please fill out the following:
Name of current insurer and date first purchased:
Limit of Liability:
Retention:
Premium:
Expiration Date:
If you have coverage for MISCELLANEOUS ERRORS & OMISSIONS, please fill out the following:
Name of current insurer and date first purchased:
Limit of Liability:
Retention:
Premium:
Expiration Date:
Has any insurer made any payments, taken notice of claim or potential claim or non-renewed any management liability or similar insurance at any time in the last three (3) years?
Yes
No
If "yes", please provide details.
PRIOR ACTIVITIES INFORMATION
Within the last three (3) years, has the Applicant or any person proposed for this insurance in his or her capacity as an employee, officer, or director of the Applicant or another entity been the subject of or involved in any litigation, civil, arbitration, administrative or criminal proceeding, civil or criminal charge or hearing, or a written demand seeking monetary or non-monetary damages?
Yes
No
If "yes", please provide details.
Within the last three (3) years, has the Applicant or any person proposed for this insurance in his or her capacity as an employee, officer, or director of the Applicant or another entity been the subject of or involved in any formal or informal investigation, proceeding or inquiry by any federal, state or local governmental agency or regulatory body, including without limitation, the U.S. Department of Justice, the U.S. Department of Labor, or any federal or state office of the Attorney General?
Yes
No
If "yes", please provide details.
Within the last three (3) years, has the Applicant or any person proposed for this insurance in his or her capacity as an employee, officer, or director of the Applicant or another entity been the subject of or involved in any notice of charges or other proceeding from the Equal Employment Opportunity Commission or any similar state or local agency or regulatory body?
Yes
No
If "yes", please provide details.
Within the last three (3) years, has the Applicant had any commercial crime losses?
Yes
No
If "yes", please provide details.
Phone
This field is for validation purposes and should be left unchanged.
