Executive Liability Underwriters
Private Company Liability Policy
Company
 Name 
 Address 1 
Address 2 
City 
State 
Zip 
Insurance Representative
  First  Initial  Last  
       
Industry Classification that Most Closely Resembles your Industry?
   
Does the company have any public debt or securities?
       Yes     No    
Operations/Financials
 Percentage of ownership held by all Directors and Officers?
   
  Most recent FYE
(000)		 Prior FYE
(000)
 Total Corporate Assets  (in thousands) $  
 Total Operating Income  (in thousands) $ $
Litigation History
 During the past three years, has there been any D&O, EPL or Fiduciary
 claims activity?		      Yes     No    
Select Desired Coverages.
D&O
EPL (specific coverage questions will apply)
Fiduciary (specific coverage questions will apply)
Employees
 Total number of employees, including full time, part time and leased or independent contractors operating solely for your Company?
   
Pension Plans
    Total Assets
(in thousands)
(000)
 Do you have a Defined Contribution Plan?      Yes     No     $
 Do you have a Defined Benefit Plan?      Yes     No     $
 Do you have a 401K Plan?      Yes     No     $
 Do you have an ESOP Plan?      Yes     No     $
 
 
 
 
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