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Directors and Officers Insurance Quote
Fill out this form for FREE Quotes
*Indicates
required information
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Contact Name:*
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Email:*
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Phone:
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Year business started:*
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# of Active Owners and/or
Partners:*
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# of Full Time Employees:*
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# of Part Time Employees:*
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# of Sub-Contractors:*
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How many years of experience does
the owner of your business have in your industry? *
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Do you have any subsidiary
businesses:
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Yes
No If yes,
how many:
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What is your business legal
entity?
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Year of Incorporation:*
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What industry is your company in?
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Detailed description of the nature of business:*
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Are you currently insured with D&O
Insurance?
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Yes
No
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If yes, what company?
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Expiration
Date:
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Approximate current annual premium for D&O insurance(0
if not applicable):
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Which of the following other
coverages does your business already have?
(check all that apply)
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Commercial
General Liability
Umbrella/Excess
Fiduciary Liability
Crime
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Approximate amount of coverage
needed:
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$1,000,000
$2,000,000
$3,000,000
$4,000,000
$5,000,000+
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Date Coverage Needed:*
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Have you merged, acquired,
purchased, sold closed, consolidated or spun off any company in the past 3
years or do you expect to in the next 12 months?
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Yes
No
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Have you reorganized or made
arrangement with creditors in the past 3 years or do you expect to in the
next 12 months?
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Yes
No
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Do you have any civil or criminal
action or administrative proceeding pending?
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Yes
No
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Are you currently the defendant in
any lawsuit?
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Yes
No
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Explanations to yes answers above
and any other information your agent should know:
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*Indicates
required information
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Enter the string of BOLD characters shown in the image at right.
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