E&O FORM

1
Enter your mail* This field is required.
example@example.com
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2
Enter your phone number* This field is required.
בבקשה הכנס מספר טלפון תקין.
3
What is the name of the company?* This field is required.
4
Address of Head Office and Country of Registration * This field is required.
5
Registration Number* This field is required.
6
Number employed* This field is required.
7
Date of Incorporation* This field is required.
Date
Year
Month
Day
8
Please provide a detailed description of your business activity:* This field is required.
Huge
Large
Normal
Small
Ok
Ok
9
Income
Last complete financial year 2022
Estimate for current financial year 2023
Estimate for next financial year
Domestic Turnover
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Row 0, Column 1
Row 0, Column 2
USA Turnover
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Other Territory Turnover
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Domestic Turnover
USA Turnover
Other Territory Turnover
Last complete financial year 2022
Row 0, Column 0
Estimate for current financial year 2023
Row 0, Column 1
Estimate for next financial year
Row 0, Column 2
Last complete financial year 2022
Row 1, Column 0
Estimate for current financial year 2023
Row 1, Column 1
Estimate for next financial year
Row 1, Column 2
Last complete financial year 2022
Row 2, Column 0
Estimate for current financial year 2023
Row 2, Column 1
Estimate for next financial year
Row 2, Column 2
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10
Does the company has any subsidiaries? * This field is required.
YESNO
11
Name of first Subsidiary* This field is required.
12
Country of Registration* This field is required.
13
Private/Public* This field is required.
Private
Public
14
Percentage Owned by the Company* This field is required.
15
Does the company has any more subsidiaries?* This field is required.
YESNO
16
Name of Second Subsidiary* This field is required.
17
Country of Registration* This field is required.
18
Private/Public* This field is required.
Private
Public
19
Percentage Owned by the Company* This field is required.
20
Is the failure of any of your products or services liable to result in any of the following outcomes:
21
Loss of life or injury to a person?* This field is required.
YesNo
22
Destruction or damage to physical property?* This field is required.
YesNo
23
Immediate and large financial loss?* This field is required.
YesNo
24
Significant cumulative financial loss?* This field is required.
YesNo
25
Insignificant financial loss (more of a nuisance)?
YesNo
26
Please explain below, and also describe the worst thing that could happen to your customers’ operations if your product / service were to fail* This field is required.
27
Approximately how many customers do you have?* This field is required.
28
What % of fees is paid to sub-contractors?* This field is required.
29
Do you carry out work only under a written contract signed by every client?* This field is required.
YESNO
30
Please provide a more details
31
Do you ever accept contracts with your customers in which you accept liability for consequential loss or financial damages, greater than the value of the contract?* This field is required.
YESNO
32
Please provide a more details
33
Have you discontinued any product or service in the past three years?* This field is required.
YESNO
34
Please provide details and reasons:
35
Please give details of the three largest contracts you have carried out in the past three years
Name of client
Business of client
Nature of your work undertaken for this contract
The total value of the project
Income to you for your contract
Start date
Completion date
A
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Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
B
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Row 1, Column 6
C
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
Row 2, Column 6
A
B
C
Name of client
Row 0, Column 0
Business of client
Row 0, Column 1
Nature of your work undertaken for this contract
Row 0, Column 2
The total value of the project
Row 0, Column 3
Income to you for your contract
Row 0, Column 4
Start date
Row 0, Column 5
Completion date
Row 0, Column 6
Name of client
Row 1, Column 0
Business of client
Row 1, Column 1
Nature of your work undertaken for this contract
Row 1, Column 2
The total value of the project
Row 1, Column 3
Income to you for your contract
Row 1, Column 4
Start date
Row 1, Column 5
Completion date
Row 1, Column 6
Name of client
Row 2, Column 0
Business of client
Row 2, Column 1
Nature of your work undertaken for this contract
Row 2, Column 2
The total value of the project
Row 2, Column 3
Income to you for your contract
Row 2, Column 4
Start date
Row 2, Column 5
Completion date
Row 2, Column 6
1 of 3
36
Have any claims or complaints (including professional services / products provided complaints) have been made against any of the companies to be insured, or partners or directors thereof?* This field is required.
YESNO
37
Are you aware, of any circumstances which may give rise to a claim against any of the companies to be insured or any partners or directors thereof?* This field is required.
YESNO
38
Have any of the companies to be insured or any partners or directors suffered any losses?* This field is required.
YESNO
39
Have any partners or directors of the companies to be insured been found guilty of any Have any of the companies to be insured or any partners or directors suffered any losses criminal, dishonest of fraudulent activity or been investigated by any regulatory authority?* This field is required.
YESNO
40
Has there ever been an unforeseen outage on your computer system(s) for more than 3 hours?
YESNO
41
Do you have a current E&O insurance in place that is not via lamda? If yes please provide details:* This field is required.
YesNo
42
Do you ever accept contracts with your customers in which you accept liability for consequential loss or financial damages, greater than the value of the contract?* This field is required.
YESNO
43
Please provide details on "yes" calims questions
44
Does the company or any of its employees act in the following countries: Cuba, Iran, Syria, Sudan, Crimea or North Korea ?-* This field is required.
YESNO
45
Please state in which of the countries listed:
46
Do you have a current e&o insurance in place that is not via lamda?
YESNO
47
Carrier
48
Premium
49
Expiry Date
Date
Month
Day
Year
50
Expiring Limit of Liability
51
Requested Limit of Liability
52
Has the Company ever had any Insurer decline a proposal or cancel or refuse to renew a E&O Insurance?If yes, please provide details
53
I declare on behalf of all insureds, after inquiry, that the statements and particulars in this supplemental proposal are true and no material facts have been misstated or suppressed. I agree that this proposal forms, any attachment, any information submitted therewith and any and all other information supplied or requested, shall form the basis of any Contract of Insurance effected thereon. All written statements and materials furnished to the insurer in conjunction with this application are hereby incorporated by reference into this application and made a part hereof. Signing this proposal does not bind the Policyholder to complete this insurance.
54
Full name of the signer+Title
Title
Full name
55
Signature
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