IP Licensing
Insurance application form
US
The purpose of this application form is for us to find out more about you. You must provide us with all information which may be
material to the cover you wish to purchase and which may influence our decision whether to insure you, what cover we offer you
or the premium we charge you.
How to complete this form
The individual who completes this application form should be a senior member of staff at the company and should ensure that they have checked
with other senior managers and colleagues responsible for arranging the insurance that the questions are answered accurately and as completely
as possible. Once completed, please return this form to your insurance broker.
Section 1: Company Details
1.1
Please state the name and address of the principal company for whom this insurance is required. Cover is also provided for the subsidiaries
of the principal company, but only if you include the data from all of these subsidiaries in your answers to all of the questions in this form.
Company name:
Primary address (Address, State, ZIP, Country):
Website:
1.2
Date business
was established (MM/DD/YYYY):
1.3
Date of compa
ny financial year end (MM/DD/YYYY):
1.4
Please state your gross revenue in respect of the last complete financial year:
$
1.5
Please provide details for the primary contact for this insurance policy:
Contact name: Position:
Email address: Telephone number:
Section 2: Activities
2.1
Please describe below the products and services supplied by your business:
CFC Underwriting Limited is Authorized and Regulated by the Financial Conduct Authority © 1999-2019 CFC Underwriting Ltd, All Rights Reserved
IP Licensing
Insurance application form
US
Section 3: License Agreement & Risk Management
3.1
Please state the following in respect of the license agreement to be covered:
a) name of the licensor:
b) its total annual value: $
c) its duration:
d) the jurisdiction governing the license agreement:
e) the permitted distribution territories:
3.2
Please describe the rights granted under the license agreement:
3.3
Please describe how you will use the rights granted under the license agreement:
Please attach a copy of the contract to this application form.
3.4
Please provide full details of your license agreement management procedures, including who is ultimately responsible for the process in
your organization and how long they have been in that position:
CFC Underwriting Limited is Authorized and Regulated by the Financial Conduct Authority © 1999-2019 CFC Underwriting Ltd, All Rights Reserved
IP Licensing
Insurance application form
US
3.5
If you require more than one license agreement to be covered, please provide answers to Q3.1-3.4 above for each license agreement you
require to be covered:
Section 4: Claims Experience
4.1
Please state whether you are aware of any incident or circumstance:
a) which may result in a claim under any of the insurance for which you are applying to purchase in this application form:
Yes
No
b) which resulted in legal action being made in relation to license agreements or breach of intellectual property against any of the
companies to be insured within the last 5 years:
Yes
No
c) which resulted in cease and desist orders being made against you:
Yes
No
If “yes” to any of the above then please describe the incident, including the monetary amount of the potential claim or the monetary
amount of any claim paid or reserved for payment by you or by an insurer. Please include all relevant dates, including a description of the
status of any current claim which has been made but has not been settled or otherwise resolved and overview of any penalties incurred.
Important Notice
By signing this form you agree that the information provided is both accurate and complete and that you have made all reasonable attempts to
ensure this is the case by asking the appropriate people within your business. CFC Underwriting will use this information solely for the purposes of
providing insurance services and may share your data with third parties in order to do this. We may also use anonymized elements of your data for the
analysis of industry trends and to provide benchmarking data. For full details on our privacy policy please visit www.cfcunderwriting.com/privacy
Contact name: Position:
Signature: Date: (MM/DD/YYYY)
CFC Underwriting Limited is Authorized and Regulated by the Financial Conduct Authority © 1999-2019 CFC Underwriting Ltd, All Rights Reserved
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