Fillable BAM New Business App (City of Oakland)

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BAM New Business App (City of Oakland)

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U.S.A. forms for City of Oakland

BROWSE CITY OF OAKLAND (CA) FORMS

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NOTICE: THE CLAIMS MADE AND REPORTED LIABILITY COVERAGE SECTIONS OR PROVISIONS OF
THIS POLICY FOR WHICH THIS APPLICATION IS BEING MADE, WHICHEVER ARE APPLICABLE,
COVER ONLY CLAIMS FIRST MADE AGAINST THE INSURED DURING THE POLICY PERIOD OR, IF
APPLICABLE, ANY DISCOVERY PERIOD AND REPORTED TO THE INSURER PURSUANT TO THE
TERMS OF THE POLICY. THE AMOUNTS INCURRED TO DEFEND A CLAIM REDUCE THE
APPLICABLE LIMIT OF LIABILITY AND ARE SUBJECT TO THE APPLICABLE RETENTION OR
DEDUCTIBLE.
Instructions: Please read carefully and answer all questions. If a question is not applicable, so state. This
Application and all exhibits shall be held in confidence. Please read the Policy for which application for coverage is
made (the "Policy") prior to completing this Application. The terms as used herein shall have the meanings as
defined in the Policy.
Applicant means all corporations, organizations or other entities set forth in Question 1. of the General Information
section of this Application, including any subsidiaries, proposed for this insurance.
I. General Information
1. Name of Applicant: __________________________________________________________
Address: ___________________________________________________________________
(Number) (Street)
___________________________________________________________________
(City) (State) (Zip Code)
2. North American Industry Classification System Code (NAICS): _________________________
3. Nature of Operations: _______________________________________________________
_______________________________________________________
_______________________________________________________
*Note – please include description of all Applicants, including any subsidiaries.
4. Website: ______________________________
Application for
Business and Management (BAM)
Indemnity Insurance
Northwest Professional Center
227 US Hwy 206, Suite 302
Flanders, NJ 07836-9174
Tel: (973) 252-5141 / (800) 689-2550
Fax: (973) 252-5146 / (800) 689-2839
www.ERiskServices.com
email: application@ERiskServices.com
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5. Has the Applicant been in business longer than three (3) years?
Yes No
6. Is the Applicant publicly-held or a public reporting company under the Securities Exchange Act of
1934, as amended?
Yes No
7. 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? If yes, please provide details on a separate page.
Yes No
8. 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? If yes, please provide details
on a separate page.
Yes No
II. Financial Information
1. 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:
$ ___________________
2. Do the current liabilities exceed current assets? If yes, please provide details on a separate page.
Yes No
3. Do long-term liabilities exceed seventy five percent (75%) of total assets? If yes, please provide
details on a separate page.
Yes No
4. Will more than fifty percent (50%) of the total long-term liabilities mature within the next eighteen
(18) months? If yes, please provide details on a separate page.
Yes No
5. Is the Applicant currently in default or anticipate in the next twelve (12) months to be in default of any
debt covenants? If yes, please provide details on a separate page.
Yes No
6. 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? If yes, please provide details on a separate page.
Yes No
7. 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? If yes,
please provide details on a separate page.
Yes No
8. 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? If yes, please provide details on a separate page.
Yes No
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III. Prior Insurance Information
1. Describe any current insurance maintained.
Coverage
Limit of Liability
Retention
Premium
Expiration Date
Employment Practices Yes
Name of Current Insurer: Date Coverage First Purchased:
Directors and Officers Yes
Name of Current Insurer: Date Coverage First Purchased:
Fiduciary Yes
Name of Current Insurer: Date Coverage First Purchased:
Commercial Crime Yes
Name of Current Insurer: Date Coverage First Purchased:
Yes
Cyber (CMTS)
Name of Current Insurer:
Date Coverage First Purchased:
Technology Errors & Omissions Yes
Name of Current Insurer: Date Coverage First Purchased:
Miscellaneous Errors & Omissions Yes
Name of Current Insurer: Date Coverage First Purchased:
2. 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? If yes, please provide
details on a separate page.
Yes No
IV. Prior Activities Information
1. 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:
a. 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
b. 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
c. 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 on a separate page.
2. Within the last three (3) years, has the Applicant had any commercial crime losses? If yes, please
provide details on a separate page.
Yes No
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V. False Information
FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any materially false information or conceals for the purpose of
misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects
such person to criminal and civil penalties. (Not applicable to Oregon).
NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to restitution fines or confinement in prison, or any combination thereof.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or
information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include
imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who
knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of
defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award payable from insurance
proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
WARNING TO DISTRICT OF COLUMBIA APPLICANTS: It is a crime to provide false or misleading information to an
insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition,
an insurer may deny insurance benefits if false information materially related to a claim was provided by the
applicant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any in-surer
files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of
the third degree.
NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to
fines and confinement in prison.
NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an
insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of
insurance benefits.
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of
a crime and may be subject to fines and confinement in prison.
NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud against
an insurer is guilty of a crime.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an
insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
NOTICE TO OKLAHOMA APPLICANTS: Any person who knowingly, and with intent to injure, defraud or deceive any
insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is
guilty of a felony.
NOTICE TO RHODE ISLAND APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of
a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject
to fines and confinement in prison.
FRAUD WARNING (APPLICABLE IN VERMONT, NEBRASKA AND OREGON): Any person who intentionally presents a
materially false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state
law.
FRAUD WARNING (APPLICABLE IN TENNESSEE, VIRGINIA AND WASHINGTON): It is a crime to knowingly provide
false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties
include imprisonment, fines, and denial of insurance benefits.
NEW YORK FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other
person files an application for insurance or statement of claim containing any materially false information, or conceals for the
purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime,
and shall also be subject to civil penalty not to exceed five thousand dollars and the stated value of the claim for each such
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violation.
VI. 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.
Signed: __________________________________________________ Date: ________________________
(must be signed by an Executive Officer of the Applicant)
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.
Please fully complete and attach the Information for the Coverage Section(s) being sought
or bound.
Any coverage part information section(s) of this Application are deemed signed and dated by the signatory in this
section VI. of the Application, unless otherwise specifically signed and dated.
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Employment Practices Coverage Section Information
Is the Applicant seeking Employment Practices coverage?
If yes, please answer the following questions.
Yes No
1. Employee and employment compensation information:
Full Time:
_______
Part Time:
_______
Seasonal:
_______
Contracted (leased, independent or otherwise):
______
a. Estimated annual remuneration of all employees, including officers, owners, or
partners:
b. Number of employees with estimated annual remuneration exceeding $100,000:
* Note: Remuneration above includes salary, commissions, bonuses and other incentives and does not include any dividends or security based
distributions.
2. Have more than twenty five percent (25%) of the officers or management voluntarily left the employ
of the Applicant or had employment with the Applicant terminated within the last eighteen (18)
months? If yes, please provide details on a separate page.
Yes No
3. Does the Applicant anticipate in the next twelve (12) months, or has the Applicant transacted in the
last twelve (12) months, any plant, facility, branch or office closing, consolidations or layoffs
affecting twenty percent (20%) or more of the employees of the Applicant? If yes, please provide
details on a separate page.
Yes No
4. Describe the internal controls the Applicant maintains for Employment Practices.
a. Have all management staff and officers attended training and education programs on sexual
harassment within the last eighteen (18) months?
Yes No
b. Does labor relations counsel review the employment policies/procedures at least annually?
Yes No
c. Is there a separate Human Resources Department?
Yes No
d. Does the Applicant publish and distribute an employee handbook to every employee?
Yes No
e. Are there written procedures for handling employee complaints of discrimination or sexual
harassment?
Yes No
f. Are there written procedures for handling employee grievances or complaints?
Yes No
g. Does the Applicant compensate all interns?
Yes No
h. Has the Applicant had in place for the past three years or since formation, whichever is the
shorter time period, written procedures and guidelines to classify the status of each employee as
Non-Exempt or Exempt under the rules and regulations of the Fair Labor Standards Act of 1938,
as amended?
Yes No
Contact information for EPL risk management services
Name:_________________________
Email:______________________
Phone:______________
Fax: ______________
This coverage part information section of the Application is deemed signed by an Executive Officer of the Applicant
and dated as of the date set forth in section VI. of this Application.
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Directors & Officers and Company Coverage Section Information
Is the Applicant seeking Directors & Officers and Company coverage?
If yes, please answer the following questions.
Yes No
1. Are more than ten percent (10%) of the outstanding securities, voting rights, or controlling interests of
the Applicant, directly or indirectly, owned by any of the following:
a. an entity or organization NOT under the direct control of a director or officer of the Applicant ?
b. a person who is NOT a current or former director or officer of the Applicant?
If yes, please provide details on a separate page.
Yes No
Yes No
2. Within the next eighteen (18) months does the Applicant anticipate any public offering or sale of
securities through any means, including any public offering of securities under the JOBS Act, as
amended? If yes, please provide details on a separate page.
Yes No
3. Does the Applicant anticipate transacting in the next eighteen (18) months or has the Applicant
transacted in the last eighteen (18) months any:
a. private debt or equity offering or sale of securities through the use of an offering prospectus,
memorandum, circular or similar document?
Yes No
b. direct sale of securities to a person or entity through any means other than the use of an offering
prospectus, memorandum circular or similar document?
Yes No
c. sale of securities, services, goods or products for the purpose of funding Applicant operations or
capital through social networking, crowdfunding, crowdsourcing or any similar mechanism?
If yes, please provide details on a separate page.
Yes No
4. Does the Applicant, directly or indirectly:
a. render any services for others for a fee or other consideration?
b. act as a general partner, manager, or managing member in any partnership or limited liability
company?
c. have any insurance operations?
d. offer, sell, advertise or market any dietary supplement or any therapeutic or medical product,
device or process where such product, device or process does NOT require approval for use from
the U.S. Food and Drug Administration (FDA)?
e. offer, sell, advertise, market, or solicit any product or service employing any automatic/robo
dialing, mobile phone texting, faxing, or any other type of communications based mechanism or
strategy governed under the rules and regulations of the Telephone Consumer Protection Act of
1991 (TCPA), as amended?
f. perform, engage in, facilitate or promote the downloading, sharing, or streaming of any
copyrighted media content, including music, video or any other type of entertainment content?
If yes, please provide details on a separate page.
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
5. Has the Applicant, in any year within the last five (5) years, annually derived more than ten percent
(10%) of its revenues or funding from federal, state, local, foreign or other governmental or quasi-
governmental sources? If yes, please provide details on a separate page.
Yes No
This coverage part information section of the Application is deemed signed by an Executive Officer of the Applicant
and dated as of the date set forth in section VI. of this Application.
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Fiduciary Coverage Section Information
Is the Applicant seeking Fiduciary Liability coverage?
If yes, please answer the following questions.
Yes No
1. Indicate the type of plans to be insured:
___
401(k)
___
Pension
___
Welfare Benefit
___
Profit Sharing
___
Employee Stock Ownership
2. Does the Applicant have more than five (5) plans to be covered under the proposed insurance? If yes,
please provide details on a separate page.
Yes No
3. Total number of employees currently enrolled in all plans:
4. Total asset value of all plans combined for the most recent fiscal year:
5. Do all of the plans conform to the standards of eligibility, participation, vesting and other provisions
of the Employee Retirement Income Security Act of 1974, as amended?
Yes No
6. Are the plans reviewed at least annually to assure that there are no violations of any plan trust
agreements, prohibited transactions or party in interest rules?
Yes No
7. Are any of the plans under funded by more than thirty percent (30%)? If yes, please provide details
on a separate page.
Yes No
8. Does the Applicant have any delinquent contributions to any plan? If yes, please provide details on a
separate page.
Yes No
9. Have any plans been terminated, suspended, merged or dissolved within the last twenty four (24)
months? If yes, please provide details on a separate page.
Yes No
10. Does the Applicant anticipate terminating, suspending, merging or dissolving any plans within the
next eighteen (18) months? If yes, please provide details on a separate page.
Yes No
11. Are more than ten percent (10%) of the assets of any plan, other than an Employee Stock Ownership
Plan, invested in any securities of or loan to the Applicant? If yes, please provide details on a
separate page.
Yes No
This coverage part information section of the Application is deemed signed by an Executive Officer of the Applicant
and dated as of the date set forth in section VI. of this Application.
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Crime Coverage Section Information
Is the Applicant seeking Crime coverage?
If yes, please answer the following questions.
Yes No
1. Total number of employees:
2. Number of officers and employees who handle, have custody or maintain records of
money, securities or other property:
3. Is there an annual audit or review performed by an independent certified public accountant (CPA) on
the books and accounts, including a complete verification of all securities and bank balances?
Yes No
4. Are bank accounts reconciled by someone not authorized to deposit or withdraw from those accounts?
Yes No
5. Is counter signature of checks required?
Yes No
6. Is the Applicant seeking Employee Benefit Plan Crime coverage?
Yes No
7. Are pre-authorized controls maintained for all programmers and operators?
Yes No
8. Do audit practices include tests to detect unauthorized programming changes?
Yes No
9. Are computerized check writing operations segregated from departments that authorize checks?
Yes No
This coverage part information section of the Application is deemed signed by an Executive Officer of the
Applicant and dated as of the date set forth in section VI. of this Application.
BAM APP (10-14)
Cyber, Media and Technology Security Services Coverage Section Information
1. Please list the gross revenues of Applicant for the most recent fiscal year-end:
$ ___________________
2. Approximate number of physical or electronic records containing personally identifiable
information the Applicant, directly or through a third party, has stored over the last twelve
months:
___________________
Yes
No
No
N/A
Yes
No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
3. Does the Applicant store, directly or through a third party, any health information records that are
governed or regulated under the Health Insurance Portability and Accountability Act (HIPAA)?
If yes, does the Applicant have procedures and audit practices in place to ensure compliance under
the rules and regulations of HIPAA, including the encryption of any electronically transmitted
records?
4. Does the Applicant use regularly updated anti-virus software and firewall configurations for
computers and networks used in business operations?
5. Does the Applicant store any personally identifiable information on unencrypted portable devices,
including laptops or external memory devices?
6. Is the critical business data of the Applicant backed-up at least once a week and stored in a secure
location?
7. Does any person to be insured have knowledge or information of any act, error, omission, fact,
circumstance or situation which might reasonably be expected to give rise to a claim or loss under
this proposed Cyber coverage? If yes, please provide details on a separate page.
8. Within the last five (5) years has the Applicant been subject to or suffered any losses or litigation
from any:
a. Breaches of security?
b. Unauthorized acquisition, access, use, identity theft, mysterious disappearance, or disclosure of
personally identifiable information?
c. Violation of any privacy law, rule or regulation?
d. Technology, ransomware or extortion threats?
If yes, please provide details on a separate page.
9. Has any insurer made any payments, taken notice of a claim or loss or a potential claim or loss or
non-renewed any cyber liability or similar insurance at any time in the last three (3) years? If yes,
please provide details on a separate page.
Yes
This coverage part information section of the Application is deemed signed by an Executive Officer of the Applicant
and dated as of the date set forth in section VI. of this Application.
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Technology, Media & Professional Services Coverage Section Information
Is the Applicant seeking Technology, Media & Professional Services coverage?
If yes, please answer the following questions.
Yes No
1. Describe in detail the professional services for which coverage is desired:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
2. Date established: __________________
3. Is the Applicant engaged in any business other than as described in question 1.?
If yes, please attach an explanation and estimated receipts.
Yes No
4. What percentage of the Applicant’s business involves subcontracting work to others?
_____%
5. List the total gross receipts for the past year, which were derived from the services, listed in question
1. In addition, please provide the projected receipts for the current and next year in which insurance
coverage is desired.
a. Gross receipts for the next year:
$ _________________
b. Gross receipts for the current year:
$ _________________
c. Gross receipts for the prior year:
$ _________________
6. What industries are the professional services described in question 1. provided (e.g., government,
banking, medical, aviation, etc.)?
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
7. Is the Applicant controlled or owned by, or associated or affiliated with, or does it own, any other
firm or business enterprise? If yes, please attach an explanation.
Yes No
8. Are any significant changes in the nature or size of the Applicant’s business anticipated over the next
twelve (12) months? Or have there been any such changes in the past twelve (12) months? If yes,
please attach an explanation (change in size of less than twenty five percent (25%) need not be
explained.)
Yes No
9. Staffing Information.
a. What is the number of all principals, partners, officers and professional employees
directly engaged in providing services to clients:
__________
b. Average years of experience for the above mentioned for services requesting coverage:
__________
c. Number of all non-professional employees (clerks, secretaries, etc.):
__________
10. Are any staff members considered “Licensed Professionals” or do any staff members hold any
professional designations or belong to any professional societies/associations? If yes, attach
individuals name and designated affiliation.
Yes No
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11. Describe Applicant’s five (5) largest jobs or projects during the past three (3) years.
Client Name
Services Provided
Total Gross Billing
$
$
$
$
$
12. Does the Applicant have a written contract or agreement for every project? If yes, please attach a
sample copy.
Yes No
a. Provide the percentage of the Applicant’s revenue where a written contract is not secured:
_____%
b. Please check below if the Applicant’s contracts contain any of the following:
hold harmless or indemnification clauses in your favor?
hold harmless or indemnification clause in your client’s favor?
guarantees or warranties?
specific description of the services you will provide?
payment terms?
ownership of materials/products developed terms?
13. Describe steps taken to minimize/manage business risks:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
14. Please provide the following information on Applicant’s professional liability insurance for the past
three (3) years:
Name of Insurer
Limits of
Liability
Deductible
Policy Period
Premium Retro Date
15. Please provide the following:
a. Standard contract(s) used.
b. Descriptive or promotional brochures.
c. Website address: www____________________________________
16. Prior to publishing content or releasing packaged or custom software/hardware, do you have an
attorney facilitate a patent/copyright/trademark search? If yes, please give name of the attorney’s
firm:______________________________
Yes No
17. Describe the Applicant’s policies and procedures for removing controversial or potentially infringing
material:
________________________________________________________________________________
________________________________________________________________________________
B
B
A
A
M
M
A
A
P
P
P
P
(
(
1
1
0
0
-
-
1
1
4
4
)
)
18. Do you have a safety procedure in place to prevent the transmission of viruses?
If yes, please explain
________________________________________________________________________________
________________________________________________________________________________
Yes No
19. Are all of your computers equipped with anti-virus software?
If yes, what brand?
____________________________________________
Yes No
20. Are firewalls in place as a part of your security system?
Yes No
a. What firewall security do you employ? ______________________________
b. Was it configured by professional personnel?
Yes No
c. Did you alter it in any way before installing it?
Yes No
21. What kind of safeguards do you have in place to prevent unauthorized persons from accessing your
Web Sites or On-Line Service database?
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
22. Have any principals, partners, officers or professional employees ever been the subject of any
reprimand or disciplinary or criminal actions by authorities as a result of their professional activities?
If yes, please attach details.
Yes No
23. Does any person to be insured have knowledge or information of any act, error or omission, which
might reasonably be expected to give rise to a claim against him or his predecessors in business? If
yes, please attach details.
Yes No
24. Have any errors and omissions claims been made against any proposed insured(s)? If yes, please
attach details.
Yes No
25. Has the Applicant been a party to any lawsuit or other legal proceedings within the past five (5) years?
If yes, please attach details.
Yes No
This coverage part information section of the Application is deemed signed by an Executive Officer of the
Applicant and dated as of the date set forth in section VI. of this Application.
B
B
A
A
M
M
A
A
P
P
P
P
(
(
1
1
0
0
-
-
1
1
4
4
)
)
Miscellaneous Professional Services Coverage Section Information
Is the Applicant seeking Miscellaneous Professional Services coverage?
If yes, please answer the following questions.
Yes No
1. Describe in detail the professional services for which coverage is desired:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
2. Date established: __________________
3. Is the Applicant engaged in any business other than as described in question 1.?
If yes, please attach an explanation and estimated receipts.
Yes No
4. What percentage of the Applicant’s business involves subcontracting work to others?
_____%
5. List the total gross receipts for the past year, which were derived from the services, listed in question
1. In addition, please provide the projected receipts for the current and next year in which insurance
coverage is desired.
a. Gross receipts for the next year:
$ _________________
b. Gross receipts for the current year:
$ _________________
c. Gross receipts for the prior year:
$ _________________
6. What industries are the professional services described in question 1. provided (e.g., government,
banking, medical, aviation, etc.)?
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
7. Is the Applicant controlled or owned by, or associated or affiliated with, or does it own, any other
firm or business enterprise? If yes, please attach an explanation.
Yes No
8. Are any significant changes in the nature or size of the Applicant’s business anticipated over the next
twelve (12) months? Or have there been any such changes in the past twelve (12) months? If yes,
please attach an explanation (change in size of less than twenty five percent (25%) need not be
explained.)
Yes No
9. Staffing Information.
a. What is the number of all principals, partners, officers and professional employees
directly engaged in providing services to clients:
__________
b. Average years of experience for the above mentioned for services requesting coverage:
__________
c. Number of all non-professional employees (clerks, secretaries, etc.):
__________
10. Are any staff members considered “Licensed Professionals” or do any staff members hold any
professional designations or belong to any professional societies/associations? If yes, attach
individuals name and designated affiliation.
Yes No
B
B
A
A
M
M
A
A
P
P
P
P
(
(
1
1
0
0
-
-
1
1
4
4
)
)
11. Describe Applicant’s five (5) largest jobs or projects during the past three (3) years.
Client Name
Services Provided
Total Gross Billing
$
$
$
$
$
12. Does the Applicant have a written contract or agreement for every project? If yes, please attach a
sample copy.
Yes No
a. Provide the percentage of the Applicant’s revenue where a written contract is not secured:
_____%
b. Please check below if the Applicant’s contracts contain any of the following:
hold harmless or indemnification clauses in your favor?
hold harmless or indemnification clause in your client’s favor?
guarantees or warranties?
specific description of the services you will provide?
payment terms?
ownership of materials/products developed terms?
13. Describe steps taken to minimize/manage business risks:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
14. Please provide the following information on Applicant’s professional liability insurance for the past
three (3) years:
Name of Insurer
Limits of
Liability
Deductible
Policy Period
Premium Retro Date
15. Please provide the following:
a. Standard contract(s) used.
b. Descriptive or promotional brochures.
c. Website address: www____________________________________
16. Have any principals, partners, officers or professional employees ever been the subject of
any reprimand or disciplinary or criminal actions by authorities as a result of their
professional activities? If yes, please attach details.
Yes No
17. Does any person to be insured have knowledge or information of any act, error or omission
which might reasonably be expected to give rise to a claim against him or his predecessors
in business? If yes, please provide details on a separate page.
Yes No
18. Have any professional liability claims ever been made against any proposed insured(s)? If
yes, please provide details on a separate page.
Yes No
This coverage part information section of the Application is deemed signed by an Executive Officer of the
Applicant and dated as of the date set forth in section VI. of this Application.
HOW DOES THE E-RISK SERVICES MANAGEMENT RESOURCES PROGRAM WORK?
Employers are provided valuable services:
© Copyright 2019 Enquiron
eriskmgmtresources.com | 877.568.6655
Free phishing testing
and online training
courses that focus on
key security areas
A simple initial
assessment to help
each organization
create a path towards
greater cyber security
preparedness
A customizable
incident response plan
and best practices
covering topics such
as phishing, mobile
protection, passwords,
incident detection
Free employee phishing testing to help employees understand risks
A simple assessment to identify an organization’s risks along with
the immediate steps to take to address them
Expert guidance to help understand cyber risks and to develop a
custom action plan
Vetted resources available for ongoing and additional cyber
protection and breach support
EMPLOYERS ARE FACING CHANGING AND POTENTIALLY COSTLY CYBER AND PRIVACY RISKS. The E-Risk Services
Management Resources program is here to help with these challenges and deliver thousands of dollars of risk management value
to your organization. These services have helped thousands of employers protect themselves from risk, and we encourage you to
take full advantage.
®
®
E-RISK SERVICES
MANAGEMENT RESOURCES
Insureds can experience this
complimentary Cyber value
by registering a valid policy
number and billing ZIP code.
Get started today.
THOUSANDS OF DOLLARS
IN ANNUAL EMPLOYER VALUE
© Copyright 2019 Enquiron
eriskmgmtresources.com | 877.568.6655
Online training
courses focused on
information directors
and officers need to
know
Unlimited, specific,
documented, and
confidential advice
from experienced D&O
attorneys
Online tools include
best practice
guidelines, checklists,
news and more
Direct access to D&O attorneys to receive confidential,
document responses to specific questions
Online risk management tools including D&O-focused
training modules
Proactive regulatory updates based on each user’s
selected preferences
Dedicated relationship managers that can help you take
full advantage of these benefits
EMPLOYERS FACE CONTINUOUSLY CHANGING D&O-RELATED LAWS AND ONGOING CHALLENGING ISSUES. The E-Risk
Services Management Resources program is here to help with these challenges and deliver thousands of dollars of risk management
value to your organization. These services have helped thousands of employers protect themselves from risk, and we encourage you
to take full advantage.
®
®
E-RISK SERVICES
MANAGEMENT RESOURCES
HOW DOES THE E-RISK SERVICES MANAGEMENT RESOURCES PROGRAM WORK?
Employers are provided valuable services:
THOUSANDS OF DOLLARS
IN ANNUAL EMPLOYER VALUE
Insureds can experience this
complimentary D&O value
by registering a valid policy
number and billing ZIP code.
Get started today.
THOUSANDS OF DOLLARS
IN ANNUAL EMPLOYER VALUE
HOW DOES THE E-RISK SERVICES MANAGEMENT RESOURCES PROGRAM WORK?
Employers are provided valuable services:
© Copyright 2019 Enquiron
eriskmgmtresources.com | 877.568.6655
Online training
courses, including
sexual harassment
prevention, available
for both supervisors
and employees
Unlimited, specific,
documented, and
confidential advice
from employment law
attorneys
Online tools: a state-
specific employee
handbook builder,
forms, posters, news,
and more
Direct access to employment law attorneys to receive confidential,
documented responses to your organization’s specific questions
A state-specific employee handbook and policy building tool and
online training courses
Live and recorded topical webinars, many with CE credits for HR
personnel
Proactive regulatory updates based on each user’s selected
preferences
EMPLOYERS FACE CONTINUOUSLY CHANGING EMPLOYMENT LAWS AND ONGOING EMPLOYEE ISSUES.
The E-Risk Services Management Resources program is here to help with these challenges and deliver thousands of dollars of risk
management value to your organization. These services have helped thousands of employers protect themselves from risk, and we
encourage you to take full advantage.
E-RISK SERVICES
MANAGEMENT RESOURCES
®
®
Insureds can experience this
complimentary EPL value
by registering a valid policy
number and billing ZIP code.
Get started today.
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Completed 17 February 2022

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