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Home > Errors Omissions > Errors & Omissions Form
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Errors & Omissions Form


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Personal Information
First Name *
Last Name *
ZIP / Postal Code *
Primary Phone Number *
E-Mail Address *
Proposed Effective Date *
/ /
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
/ /
Transaction Type
Claims made *
Occurence *
Proposed Retroactive Date *
/ /
Deductible *
Limits of Liability
Each claim *
Each occurrence *
Aggregate *
Retained Limit
Amount *
Defense included within limit? *

First dollar defense? *

Products & Services
Fiscal Year Begins on *
/ /
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? *



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? *

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

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? *

Please list all products that you have discontinued making, but which are still being used
Do you have a formal product recall plan? *

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? *

Do you normally install and service your products? *

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

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? *

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? *

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

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

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? *

If yes, please explain
Marketing / Contracts
Does your legal counsel review and approve all contracts, advertising, and promotional materials, and brochures? *

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

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? *

Do all of your contracts include the following?




General Information
Explain all 'Yes' responses in Remarks section
Are you a member of a professional organization related to your business? *

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

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? *

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 *
/ /
Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
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Phone: 888.504.4030
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