Commercial Lines – Employer’s Practices & Liability ApplicationEmet Digital2019-01-02T12:23:32-08:00 Get started by filling out this form and someone from our team will contact you shortly! Commercial - Employer's Practices & Liability Application CLIENT INFORMATIONName of Applicant* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code What type of business is this?* For Profit Not For Profit North American Industry Classification System Code (NAICS): Nature of Operations:*Website: Has the Applicant been in business longer than three (3) years? Yes No Is the Applicant a publicly-held or a public reporting company under the Securities Exchange Act of 1934, as amended? Yes No Has the Applicant been involved with, negotiated, attempted or transacted any merger, acquisition, asset sale or divestment in the past eighteen (18) months where such merger, acquisition, asset sale or divestment involved more than twenty five percent (25%) of the total assets or securities of the Applicant? Yes No If "yes", please provide details.Does the Applicant contemplate transacting any merger, acquisition, asset sale or divestment in the next twelve (12) months where such merger, acquisition, asset sale or divestment would involve more than fifty percent (50%) of the total assets or securities of the Applicant? Yes No If "yes", please provide details.FINANCIAL INFORMATIONDescribe the following financial information of the Applicant for the most recent fiscal year-end.Total AssetsGross RevenuesNet IncomeNet LossCash flow from operating activities Do the current liabilities exceed current assets? Yes No If "yes", please provide details.Do long-term liabilities exceed seventy five percent (75%) of total assets? Yes No If "yes", please provide details.Will more than fifty percent (50%) of the total long-term liabilities mature within the next eighteen (18) months? Yes No If "yes", please provide details.Is the Applicant currently in default or anticipate in the next twelve (12) months to be in default of any debt covenants? Yes No If "yes", please provide details.Does the Applicant anticipate in the next twelve (12) months or has the Applicant transacted in the last twenty four (24) months any restructuring or legal or financial reorganization or filing for corporate bankruptcy? Yes No If "yes", please provide details.Does any person or entity who owns or controls fifty percent (50%) or more of the outstanding securities of the Applicant anticipate in the next twelve (12) months filing for or has any such person or entity within in the last twenty four (24) months filed for personal or corporate bankruptcy? Yes No If "yes", please provide details.Does the Applicant have any actual or potential earn-out or other contingent payment obligation in the next twenty four (24) months to any person or entity where such payment obligation exceeds $500,000? Yes No If "yes", please provide details.PRIOR INSURANCE INFORMATIONDescribe any current insurance maintained. If you have coverage for EMPLOYMENT PRACTICES, please fill out the following:Name of current insurer and date first purchased:Limit of Liability:Retention:Premium:Expiration Date: If you have coverage for DIRECTORS and OFFICERS, please fill out the following:Name of current insurer and date first purchased:Limit of Liability:Retention:Premium:Expiration Date: If you have coverage for FIDUCIARY, please fill out the following:Name of current insurer and date first purchased:Limit of Liability:Retention:Premium:Expiration Date: If you have coverage for COMMERCIAL CRIME, please fill out the following:Name of current insurer and date first purchased:Limit of Liability:Retention:Premium:Expiration Date: If you have coverage for PRIVACY/PRIVACY BREACH, please fill out the following:Name of current insurer and date first purchased:Limit of Liability:Retention:Premium:Expiration Date: If you have coverage for TECHNOLOGY ERRORS & OMISSIONS, please fill out the following:Name of current insurer and date first purchased:Limit of Liability:Retention:Premium:Expiration Date: If you have coverage for MISCELLANEOUS ERRORS & OMISSIONS, please fill out the following:Name of current insurer and date first purchased:Limit of Liability:Retention:Premium:Expiration Date: Has any insurer made any payments, taken notice of claim or potential claim or non-renewed any management liability or similar insurance at any time in the last three (3) years? Yes No If "yes", please provide details.PRIOR ACTIVITIES INFORMATIONWithin the last three (3) years, has the Applicant or any person proposed for this insurance in his or her capacity as an employee, officer, or director of the Applicant or another entity been the subject of or involved in any litigation, civil, arbitration, administrative or criminal proceeding, civil or criminal charge or hearing, or a written demand seeking monetary or non-monetary damages? Yes No If "yes", please provide details.Within the last three (3) years, has the Applicant or any person proposed for this insurance in his or her capacity as an employee, officer, or director of the Applicant or another entity been the subject of or involved in any formal or informal investigation, proceeding or inquiry by any federal, state or local governmental agency or regulatory body, including without limitation, the U.S. Department of Justice, the U.S. Department of Labor, or any federal or state office of the Attorney General? Yes No If "yes", please provide details.Within the last three (3) years, has the Applicant or any person proposed for this insurance in his or her capacity as an employee, officer, or director of the Applicant or another entity been the subject of or involved in any notice of charges or other proceeding from the Equal Employment Opportunity Commission or any similar state or local agency or regulatory body? Yes No If "yes", please provide details.Within the last three (3) years, has the Applicant had any commercial crime losses? Yes No If "yes", please provide details.NameThis field is for validation purposes and should be left unchanged.
