Commercial Lines – Intellectual Property (IP)Emet Digital2019-01-02T12:07:53-08:00 Get started by filling out this form and someone from our team will contact you shortly! Commercial - Intellectual Property (IP) CLIENT INFORMATIONApplicant's Name* First Last *Applicant Name (s) will be the policy holder. If you need additional insureds there will be a place to list them later.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 Phone number*Website Contact Name* First Last Contact Address (if different from above) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Contact Phone*Contact Email* Contact FaxUNDERWRITING INFORMATIONCompany TypeCorporationIndividualPartnershipOtherDate of Incorporation (formation) MM slash DD slash YYYY Continuously operating since: Please describe the nature of your business.Should coverage be offered, please indicate the Future Requested Effective Date. Please list all additional insureds for which coverage is sought and their relationship to the MPMW.Are you now planning, or in the last five (5) years have you or anyone representing you, your Company or any related company been involved in, any merger, acquisition, joint venture or purchase of business assets, including communications, discussions or negotiations which did not lead to a transaction? Yes No If "Yes", please provide details.Requested Policy Limit - Per Claim.$250,000$500,000$750,000$1,000,000$2,000,000$3,000,000$4,000,000$5,000,000*Please indicate your interest.Requested Policy Limit - Aggregate$250,000$500,000$750,000$1,000,000$2,000,000$3,000,000$4,000,000$5,000,000*Aggregate Limits available are the same as per Claim Limits or higher. Please indicate your interestHave you had IP Defense insurance before? Yes No If “Yes”, please provide the name of carrier, limits, premium, and expiration date of the policy.Indicate if you or your Company have been involved in any of the following:International Trade commission actions? Yes No Declaratory judgment actions? Yes No PATENTS, TRADEMARK or COPYRIGHT related CIVIL PROCEEDINGS or settlement? Yes No Other post-grant procedures (oppositions, reissue, re-exams, etc.)? Yes No Other litigation of any kind filed by or against you in the past 3 years, including state actions? Yes No If your answer to any of the above is “yes,” briefly give details and outcome.MPMWWhat SIC codes apply to the MPMW? Are you currently in business selling the MPMW? Yes No What ownership/contractual rights or relationship do you have to the MPMW? Owner Licensee Assignee Distributor Retailer User Other *Please check all that applyIf "Other", please explain Are you required by contract to carry IP Defense insurance? Yes No If “Yes”, please provide details of type of contract, with whom, and limits required.Is the MPMW to be insured manufactured by you? Yes No Is the MPMW to be insured manufactured for you? Yes No Is the MPMW to be insured manufactured by another under license from you? Yes No Have you previously had or are you now engaged in any disputes with any of your licensors or product suppliers (manufacturers)? Yes No If "Yes", please give details.How many end uses are there for the MPMW to be insured? Do the MPMW:Involve the use of relatively scarce raw materials? Yes No Require special manufacturing equipment? Yes No Involve the use of extraordinary or scarce labor skills? Yes No Have any special power, fuel, energy, water or environmental requirement? Yes No Generate toxic wastes or involve hazardous conditions? Yes No Are any confidential trade secrets or know-hows used in any process/invention/device or MPMW to be insured? Yes No Would you consider taking a license on the MPMW to be insured if you were likely to be found to infringe on another’s intellectual property rights? Yes No Are there presently, in the market, similar or competing alternatives to the MPMW to be insured? Yes No If “Yes”, are there patent, trademark or copyright numbers, symbols, or pending notices on such devices? Yes No If "Yes", please give the numbers. Estimate the number of companies that directly compete with your MPMW in the marketplace. None Less than 5 5-10 10-20 More than 20 Indicate the names of your top five (5) closest competitors and their geographic market (US and/or foreign). Include yourself.If any of the above competitors are likely to hold patents, trademarks or copyrights on their products, please list which ones: Categorize your company and the top five (5) competitors with regard to Total Sales:#1 Company and its Estimated Total Annual Sales#2 Company and its Estimated Total Annual Sales#3 Company and its Estimated Total Annual Sales#4 Company and its Estimated Total Annual Sales#5 Company and its Estimated Total Annual SalesApplicant's Company and Estimated Total Annual Sales Your Sales in the Previous Year:USForeignTotal Your Sales in the Current Year:USForeignTotal Your Sales in the Next Year:USForeignTotal Please attach a current financial statement, audited if available, and/or Form 10K, if publicly traded.Max. file size: 50 MB.What is the average market life of the MPMW? Less than 1 year 1-3 years 3-5 years 5-10 years Over 10 years Estimate the total size of the U.S. market for the MPMW to be insured. Less than $1M $1M - $10M $10M - $100M $100M - $500M List each company and the number of years the product or process to be insured has been used or sold by you and your competitors:#1 Company and Number of Years#2 Company and Number of Years#3 Company and Number of Years#4 Company and Number of Years#5 Company and Number of YearsApplicant's Company and Number of Years Who are the principal customers served by Your business? Does your business involve “aftermarket supply” or re-seller market (e.g., automotive replacement parts, printer ink replacement, long distance telephone re-seller)? Yes No Please give details for the above.Estimate the average % Net Profit (before interest and taxes) experienced by your company, for the company as a WHOLE. Less than 5% 5% - 10% 10% - 20% 20% - 40% More than 40% Estimate the average % Net Profit (before interest and taxes) experienced by your company, for INSURED MPMW ONLY. Less than 5% 5% - 10% 10% - 20% 20% - 40% More than 40% Have you ever been a Defendant in a patent, trademark or copyright infringement lawsuit? Yes No If "Yes", please provide details.Do you have an intellectual property attorney on staff with full time responsibilities for filing PATENTS, TRADEMARKS, or COPYRIGHTS, giving advice about potential infringements and other intellectual property legal advice? Yes No If "Yes", please provide the name(s) of the attorney(s). Do you have an outside, independent law firm that regularly provides you intellectual property legal advice? Yes No If "Yes", please provide the name of the law firm, its address, and the attorney who is your contact.Do you use confidentiality/non-compete agreements in all your IP negotiations? Yes No What are your average IP related defense costs for the last three years?Last Year2 Years Ago3 Years Ago Are you aware of any facts or circumstances not otherwise disclosed on this application which could reasonably increase the likelihood that another party might accuse you of infringing upon its intellectual property? Yes No If "Yes", please provide details.SPECIFIC IP DEFENSE COVERAGESThe questions following pertain to the specific IP defense coverages you wish to purchase. Please answer only those that apply (e.g. if you are only insuring against patent infringement charges, then answer ALL of the questions which relate to “Patents” and skip the ones which relate to Trademarks and Copyrights).Questions for coverage against charges of “PATENT” infringement:As part of this application, we request a copy of any infringement search and opinion(s) (freedom to manufacture opinion) from outside counsel. Include references cited, if any. If you need a sample format for this search & opinion, please notify us for a copy of the format. We may also be able to assist you in obtaining this search & opinion, or an alternative insurability report which will satisfy our underwriting requirements.Product/Process Name for which insurance is being requested: Please attach any literature you may have describing your product/process. It is important that we have a clear understanding of the MPMW you wish to insure.Max. file size: 50 MB.Date of first commercial sales: MM slash DD slash YYYY Do you hold PATENTS, PATENT applications, or anticipate filing a PATENT application(s) on the product/process to be insured? Yes No If "Yes", please provide a brief explanation of the inventive features covered.List your ten (10) most important PATENTS and their numbers:Are the PATENTS listed above licensed to anyone? Yes No If “Yes”, please identify Licensee and type of license (i.e. exclusive, non-exclusive, sole, territorial, products/processes, payments, royalties, duty to enforce, defend, etc.).Are you obligated to defend any third party for patent infringement vis-à-vis the product being insured? Yes No If "Yes", please identify: Are any products/processes (MPMW) to be insured licensed by you TO others (i.e. you are the licensor)? Yes No If "Yes", please identify. Are any products/processes (MPMW) to be insured licensed by you FROM others (i.e. you are the licensee)? Yes No If "Yes", please identify. In designing your product, did you copy or design around any third party patents? Yes, copied Yes, designed Neither *check all that applyIf "Yes" to either, please identify patent number(s): Do you have knowledge of existing infringements of the product/process to be insured either in the U.S. or in foreign countries of patents of others? (For example, are you currently using any patented features of another without their authorization?) Yes No If “Yes”, please provide details, including the name of the other party and date you intend to begin this use.Do you have knowledge of suspected or anticipated infringements of other’s patent rights? For example, do you anticipate or are you about to use the patented features of another without their authorization? Yes No If “Yes”, please provide details, including the name of the other party and date you intend to begin this use.Do you have knowledge of activities outside the U.S. which if conducted in the U.S. would be an infringement? For example, are you using any patented features of another overseas without their authorization? Yes No If “Yes”, please provide details, including the name of the other party and date you first began this use.Have you received any warning letters or notices of infringement from anyone concerning the product to be insured? Yes No If "Yes", please attach copies.Max. file size: 50 MB.Have you been offered and have refused a license covering any of the products to be insured? Yes No If “Yes”, please provide details, including name(s).Are there any circumstances of which the Applicant is aware (including existing or threatened lawsuits) that could reasonably be expected to give rise to IP litigation against the Applicant? Yes No If "Yes", please provide details.Is this policy being sought to cover any MPMW loss, costs or expenses vis-à-vis filing an abbreviated or new drug application (ANDA or NDA) with the FDA under the Hatch Waxman Act? Yes No If "Yes", please provide details.Has the MPMW ever been involved in any Hatch Waxman proceedings? Yes No If "Yes", please provide details.Indicate the number of patents held/controlled/licensed by you. Questions for Coverage Against Charges of "TRADEMARK" infringement*As part of this application, we request a copy of any infringement search and opinion(s) (freedom to use opinion) from outside counsel. Include references cited, if any. If you need a sample format for this search & opinion, please notify us for a copy of the format. We may also be able to assist you in obtaining this search & opinion or an alternative insurability report which will satisfy our underwriting requirements.Identify a list of the marks, symbols, designations or TRADE DRESS you own, control or license (MPMW) for which you would like coverage. T/M registration number (if applicable) or identifying features of symbol, mark, designation or trade dress (MPMW). Add the registration date (if applicable), the date the sales began and the country.Please also attach any literature describing your MPMW to be insured. It is important that we have a clear understanding of the MPMW you wish to insure.)Max. file size: 50 MB.Indicate the number of TRADEMARKS held/controlled/licensed by you. Do you have an obligation to defend a third party vis-à-vis the marks, symbols, designations or TRADE DRESS (MPMW) to be insured? Yes No If "Yes", please identify party or parties.Are any marks, symbols, designations or TRADE DRESS (MPMW) to be insured licensed by you to others (i.e. you are the licensor)? Yes No If "Yes", please identify party or parties.Are any marks, symbols, designations or TRADE DRESS (MPMW) to be insured licensed by you from others (i.e. you are the licensee)? Yes No If "Yes", please identify party or parties.Has anyone else registered the same or a similar mark, symbol, designation or TRADE DRESS (MPMW) in a different class? Yes No If "Yes", please list the classes and the owners.Is any part of the MPMW to which the marks, symbols, designations or TRADE DRESS to be insured are applied covered by COPYRIGHT(s) or PATENT(s)? Yes, Copyright(s) Yes, Patent(s) Neither *check all that applyDoes anyone else have a right in the marks, symbols, designations or TRADE DRESS (MPMW) to be insured? Yes No If "Yes", please identify party or parties.Have you notified anyone that the marks, symbols, designations or TRADE DRESS (MPMW) for which insurance is sought are infringed by them? Yes No If "Yes", to whom?Do you have knowledge of existing infringements of the MPMW to be insured either in the U.S. or in foreign countries of trademarks of others? For example, are you currently using any trademark of another without their authorization? Yes No If “Yes”, please provide details, including the name of the other party and date you first began this use.Do you have knowledge of suspected or anticipated infringements of other’s trademark rights? For example, do you anticipate or are you about to use a trademark of another without their authorization? Yes No If “Yes”, please provide details, including the name of the other party and date you intend to begin this use.Do you have knowledge of activities outside the U.S. which if conducted in the U.S. would be a trademark infringement? For example, are you using any trademark of another overseas without their authorization? Yes No If “Yes”, please provide details, including name of other party and date you first began this use.Have you received any warning letters or notices of infringement from anyone that you might be infringing their trademark? Yes No If "Yes", please attach copies.Max. file size: 50 MB.Have you received offers for license under any trademark of another which you have refused or denied? Yes No If "Yes", please provide details.Are any of your TRADEMARKS famous? Yes No If "Yes", please list the trademarks and describe their fame.Are you aware of any famous trademarks that are similar to any of your TRADEMARKS, even if they are in a different area of commerce? Yes No If “Yes”, please list and describe those trademarks and their relationship to your area of commerce.Questions for Coverage Against Charges of "COPYRIGHT" InfringementIdentify below the Works of Authorship you own, control or license (MPMW) for which you would like coverage. Include COPYRIGHT Registration Number (if applicable) and a list of identifying features of Works of Authorship (MPMW). Include the registration date (if applicable), the date sales began and the country.Please also attach any literature describing your MPMW to be insured, It is important that we have a clear understanding of the MPMW you wish to insure.Max. file size: 50 MB.Indicate the number of COPYRIGHTS held/controlled/licensed by you. Do you have an obligation to defend a third party vis-à-vis the Works of Authorship (MPMW) to be insured? Yes No Are any Works of Authorship (MPMW) to be insured licensed by you to others (i.e. you are the licensor)? Yes No If "Yes", please identify party or parties.Are any Works of Authorship (MPMW) to be insured licensed by you from others (i.e. you are the licensee)? Yes No If "Yes", please provide copies of licensee(s) or written permission(s).Max. file size: 50 MB.Has anyone else registered or asserted copyright rights in the same or similar Works of Authorship (MPMW) in a different class? Yes No If "Yes", please list classes and owners.Is any part of the MPMW to which the Works of Authorship to be insured covered by TRADEMARK(s) or PATENT(s)? Yes, Trademark(s) Yes, Patent(s) No, neither *check all that applyDoes anyone else have a right in the Works of Authorship (MPMW) to be insured? Yes No If "Yes", please identify party or parties.Have you notified anyone that the Works of Authorship (MPMW) for which insurance is sought are infringed by them? Yes No If "Yes", to whom?Do you have knowledge of existing infringements of the MPMW to be insured either in the U.S. or in foreign countries of copyrights of others? For example, are you currently using any Works of Authorship of another without their authorization? Yes No If “Yes”, please provide details, including the name of the other party and date you first began this use.Do you have knowledge of possible infringement of the MPMW to be insured? For example, are you about to use Works of Authorship similar to those of another without their authorization? Yes No If “Yes”, please provide details, including the name of the other party and date you intend to begin this use.Do you have knowledge of activities outside the U.S. which, if conducted in the U.S., would be a copyright infringement? For example, are you using any Works of Authorship of another overseas without their authorization? Yes No If “Yes”, please provide details, including the name of the other party and date you first began this use.Have you received any warning letters or notices of infringement from anyone that you might be infringing their copyright? Yes No If "Yes", please submit copies.Max. file size: 50 MB.Have you received offers for license under any copyright of another which you have refused or denied? Yes No If "Yes", please provide details.NameThis field is for validation purposes and should be left unchanged.
