Errors & Omissions Form

Personal Information

First Name *

Last Name *

ZIP / Postal Code *

Primary Phone Number *

E-Mail Address *

Proposed Effective Date *

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List all mergers or acquisitions by your company (including subsidiaries) in past 5 years

List all joint ventures in which your company is a partner

Policy / Coverage Information

Expiring Policy #

Current retroactive date

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Transaction Type

Claims made *

Occurence *

Proposed Retroactive Date *

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Deductible *

Limits of Liability

Each claim *

Each occurrence *

Aggregate *

Retained Limit

Amount *

Defense included within limit? *

Yes
No

First dollar defense? *

Yes
No

Products & Services

Fiscal Year Begins on *

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Total estimated gross sales for the following periods

Last Fiscal Year

Domestic *

Foreign *

Total *

Current Fiscal Year

Domestic *

Foreign *

Total *

Next Fiscal Year

Domestic *

Foreign *

Total *

List each product line or service you provide and the related sales *

List each manufactured electronic product, precision instrument, or medical device you make or sell

Retail sales amount *

Wholesale sales amount *

Income from other business activities

What is the acceptable downtime for your product/service according to your average customer's needs? *

No downtime acceptable
Downtime of less than 1 day is acceptable
Downtime of less than 2 days is acceptable
More than 2 days of downtime is acceptable

What is the worst thing that could happen to your customers' operations if your product/service were to fail or stop working? *

What is the average life expectancy of each of your products? *

What is the average cost of a sale or contract with an individual customer? *

What is the value of your largest sale or project? *

Name your 5 largest customers *

List any new products or services you plan to introduce in the upcoming year

Product Development & Quality Control

Briefly explain your product development methodology *

What is the title of the person who has primary responsibility for your quality assurance program? *

Describe your quality assurance program *

List all products and quality assurance standards, such as ISO 9000, for which you are certified

Do you conduct formal inspections of requirements, design code, and test plans? *

Yes
No

Do you require your customers to sign off at critical milestones of a project? *

Yes
No

What percent of your products or services do you design yourself? *

Are redundant systems or warnings built into your product to prevent or warn against product failure? *

Yes
No

Please list all products that you have discontinued making, but which are still being used

Do you have a formal product recall plan? *

Yes
No

If you have ever had to recall a product, please explain the circumstances

Do you have contingency plans to service a customer who has had a critical failure of your product or service? *

Yes
No

Do you normally install and service your products? *

Yes
No

Do you provide service and repair of products other than your own? *

Yes
No

If so, what is the % of total service revenue generated by this work?

Suppliers

What % of your component parts are supplied by outside vendors?

What % of your suppliers' components or parts are designed by your company, but manufactured by your supplier?

What % of your component parts are supplied by foreign based companies?

Do you ever agree to hold harmless any suppliers for claims arising out of their products? *

Yes
No

If yes, please explain

Sub & Independent Contractors

What, if any, development or product work do you contract out?

Do you require anyone to whom you contract work, to have products and E&O coverage? *

Yes
No

If yes, are you named as an additional insured on their policy?

Yes
No

Do you require anyone to whom you contract work, to provide you with certificates of insurance? *

Yes
No

Distribution

State the % of your products that are directly shipped to the following

Other manufacturers *

Wholesalers *

Retailers *

Consumers *

Others *

If others, please specify

Do you ever agree to hold harmless any dealers for claims arising out of your products? *

Yes
No

If yes, please explain

Marketing / Contracts

Does your legal counsel review and approve all contracts, advertising, and promotional materials, and brochures? *

Yes
No

Do you require your customers to sign written agreements that outline the specifications of products and services you will provide? *

Yes
No

Describe the training of your sales staff in terms of teaching them the characteristics and capabilities of your products and services *

Is your sales staff specifically instructed not to exaggerate the capabilities of your products or services? *

Yes
No

Do all of your contracts include the following?

Force Majeure
Disclaimer of Warranties
Limitation of Liabilities
limitation of Liabilities for Consequential Damage
Conditions of Product Acceptance

General Information

Explain all 'Yes' responses in Remarks section

Are you a member of a professional organization related to your business? *

Yes
No

Are any of your products used in the aircraft, space, medical, robotics, pollution or environmental industries? *

Yes
No

Prior Incidents

If you are requestion that the retroactive date of this policy be dated prior to the effective date of this policy, provide any information that you know of that may result in a claim being made during the covered period.

Failure to report such information may void coverage in this policy.

Are you aware of any prior incidents or problems which may lead to a claim being made against your company? *

Yes
No

Please describe any prior incidents

Remarks

I certify that I am authorized employee of the propective named insured. It is agreed that this application shall be the basis upon which a policy may be issued.

Date *

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