Nova Risk Transfer Insurance Application

Application For Insurance

NOVA RISK TRANSFER INSURANCE COVERAGE Provided through Davies Group Continental Building, 25 Church Street Hamilton, Bermuda HM 12
Section 1: Applicant Information
Business Details*

Name of BusinessName of Authorized Individual (Director, Officer or Authorized Signatory)
EIN/Tax ID*
Plesae select Industry or Sector of Operations*
Registered Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If the trading address is different from the registered address, please complete this section

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please enter a valid phone number.
Details of the Individual submitting this Application*

First NameLast Name
Applicant Contact Email*
example@example.com
Details of the Individual referring you to this Application:*

First NameLast Name
Referring Contact Email
example@example.com
Best Contact Phone Number*
Please enter a valid phone number.
Section 2: Business Information
Entity Type*
When was the business established?*
What is the anticipated net income for the Year? *
Website
Please provide the Business' website
Please provide a 1-2 paragraph description of the products or services that are offered by the business*
Section 3: Current Financial Information

Please attach copies of the Applicant’s Tax Returns for the last two years (Form 1065 or 1120, or equivalent) or the two latest Audited Financial Statements (P&L etc.):
File Upload*

Cancelof
File Upload*

Cancelof
Section 4: Coverage Information

A. Does the Business currently have any of the following insurance coverages?

	Limit of coverage	Premium	Value of Claims in the last 5 Years
Business Interruption
Commercial Liability
Professional Indemnity
Life Insurance
Product Liability
Errors and Omissions
Directors and Officers

B. Please select all the risks you would like to insure:

	Checkbox
Loss of Key Customer Revenue (complete item C below)
Loss of Key Employee Revenue (complete item C below)
Loss of Key Contractual Relationship Revenue (complete item C below)
Loss of Key Supplier Revenue (complete item C below)
Loss of Revenue due to Breach of Contract
Loss due to Business Litigation Expense
Loss due to a Change in Law
Errors & Omissions
Loss of Revenue due to Administrative Action
Loss of Revenue due to Changes in Tenant Laws
Loss of Revenue due to Civil Disorder
Loss of Revenue due to Economic Collapse
Loss of Property Value due to Eminent Domain
Loss of Revenue due to Employment Practices Liability
Loss due to Foreclosure Expenses
Loss of Revenue due to Fraudulent Actions by Tenants
Loss due to a HIPAA Violation
Loss of Revenue due to Suspension of Professional License
Loss of Revenue due to Payment Default by Tenants
Loss of Revenue due to Changes in Federal or State Transportation Law
Loss of Revenue due to Bankruptcy of Customers
Loss of Revenue due to Bankruptcy of Suppliers
Loss of Revenue due to Unintentional Copyright Theft
Loss of Revenue due to Failure of Public Utilities
Loss of Revenue due to Unintentional Patent Theft or Infringement
Loss of Revenue due to Supply Chain Failure or Delays
Loss of Revenue due to Reputational Damage as a result of Not Complying With Regulations
Loss of Revenue due to Reputational Damage as a result of Data Breaches
Loss of Revenue due to Reputational Damage as a result of Legal Action
Loss of Revenue due to Reputational Damage as a result of Significant Layoffs
Loss of Revenue due to Reputational Damage as a result of Unethical Working Conditions
Loss of Revenue due to Reputational Damage as a result of Unethical Conduct
Loss of Revenue due to Reputational Damage as a result of Employees Misconduct
Loss of Revenue due to Reputational Damage as a result of Negative Social Media Posts by Those Associated With Your Business
Loss of Revenue due to Reputational Damage as a result of Defamation
Loss of Revenue due to Reputational Damage as a result of Negative Media by Public Personalities

The business must have an insurable interest in the risk which is seeking to insure. The total insured value sought may not exceed the loss expected in the event of a claim. A minimum of four risks must be selected in order to ensure adequate programme diversification.

C. If you selected any of the coverage options above, please specify coverage details:

	Name of Individual, Business, or Relationship
Loss of Key Customer Revenue
Loss of Key Employee Revenue
Loss of Key Contractual Relationship Revenue
Loss of Key Supplier Revenue

Section 5: Premium Financing
An application for Premium Financing must be completed on the Approved Lender's website.

Please click on this link to The Einstein Group application page (opens in a new window).

You can also complete it at the end of this application.
Section 6: Declaration and Submission
Nova will review the details provided in this Application and provide an underwriting evaluation and proposal at no cost. This no-cost underwriting evaluation shall include no less than four risks to be insured in order to appropriately diversify your portfolio, subject on the information provided in this Application .

By accepting a proposal from Nova the Applicant declares the following:

The undersigned Applicant, by submitting this Application, hereby applies for Excess & Surplus lines insurance coverage on a self-procurement basis from Davies Insurance Limited f.o.b of Nova Risk Transfer Segregated Account

The Applicant hereby agrees, understands, represents and warrants the following:

a. This Application constitutes an offer from the Applicant to buy insurance and it is made on a self-procurement basis. It is applying for insurance coverage on an unsolicited basis;

b. All information and answers provided in this Application are declared to be true, full and complete to the best of the Applicant’s knowledge and belief and can be relied upon for the purposes of insurance coverage;

c. The Applicant hereby agrees to be bound by all the terms set forth in the Policy issued by the carrier and may not rely on any other written or oral information provided by others.
I hereby agree to the above statements:*

First and Last NameInitials
Business Name
Should be Empty:

Application For Insurance

Section 1: Applicant Information

Section 2: Business Information

Section 3: Current Financial Information

Section 4: Coverage Information

Section 5: Premium Financing

Section 6: Declaration and Submission