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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
Required
Last Name
Required
ZIP / Postal Code
Required
Primary Phone Number
Required
E-Mail Address
Required
Proposed Effective Date
Required
/ /
List all mergers or acquisitions by your company (including subsidiaries) in past 5 years
Optional
List all joint ventures in which your company is a partner
Optional
Policy / Coverage Information
Expiring Policy #
Optional
Current retroactive date
Optional
/ /
Transaction Type
Claims made
Required
Occurence
Required
Proposed Retroactive Date
Required
/ /
Deductible
Required
Limits of Liability
Each claim
Required
Each occurrence
Required
Aggregate
Required
Retained Limit
Amount
Required
Defense included within limit?
Required

First dollar defense?
Required

Products & Services
Fiscal Year Begins on
Required
/ /
Total estimated gross sales for the following periods
Last Fiscal Year
Domestic
Required
Foreign
Required
Total
Required
Current Fiscal Year
Domestic
Required
Foreign
Required
Total
Required
Next Fiscal Year
Domestic
Required
Foreign
Required
Total
Required
List each product line or service you provide and the related sales
Required
List each manufactured electronic product, precision instrument, or medical device you make or sell
Optional
Retail sales amount
Required
Wholesale sales amount
Required
Income from other business activities
Optional
What is the acceptable downtime for your product/service according to your average customer's needs?
Required



What is the worst thing that could happen to your customers' operations if your product/service were to fail or stop working?
Required
What is the average life expectancy of each of your products?
Required
What is the average cost of a sale or contract with an individual customer?
Required
What is the value of your largest sale or project?
Required
Name your 5 largest customers
Required
List any new products or services you plan to introduce in the upcoming year
Optional
Product Development & Quality Control
Briefly explain your product development methodology
Required
What is the title of the person who has primary responsibility for your quality assurance program?
Required
Describe your quality assurance program
Required
List all products and quality assurance standards, such as ISO 9000, for which you are certified
Optional
Do you conduct formal inspections of requirements, design code, and test plans?
Required

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

What percent of your products or services do you design yourself?
Required
Are redundant systems or warnings built into your product to prevent or warn against product failure?
Required

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

If you have ever had to recall a product, please explain the circumstances
Optional
Do you have contingency plans to service a customer who has had a critical failure of your product or service?
Required

Do you normally install and service your products?
Required

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

If so, what is the % of total service revenue generated by this work?
Optional
Suppliers
What % of your component parts are supplied by outside vendors?
Optional
What % of your suppliers' components or parts are designed by your company, but manufactured by your supplier?
Optional
What % of your component parts are supplied by foreign based companies?
Optional
Do you ever agree to hold harmless any suppliers for claims arising out of their products?
Required

If yes, please explain
Optional
Sub & Independent Contractors
What, if any, development or product work do you contract out?
Optional
Do you require anyone to whom you contract work, to have products and E&O coverage?
Required

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

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

Distribution
State the % of your products that are directly shipped to the following
Other manufacturers
Required
Wholesalers
Required
Retailers
Required
Consumers
Required
Others
Required
If others, please specify
Optional
Do you ever agree to hold harmless any dealers for claims arising out of your products?
Required

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

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

Describe the training of your sales staff in terms of teaching them the characteristics and capabilities of your products and services
Required
Is your sales staff specifically instructed not to exaggerate the capabilities of your products or services?
Required

Do all of your contracts include the following?
Optional




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

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

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?
Required

Please describe any prior incidents
Optional
Remarks
Optional
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.
Optional
Date
Required
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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.

 

cpalmer@neighborhoodinsuranceservice.com

            
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