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Directors & Officers Liability Coverage
General Information
Applicant Name
*
Applicant Title
*
Applicant Address (street, city, state, zip)
*
Applicant Contact Name and Title
*
Applicant Contact Phone Number
Applicant Email
WhatsApp Phone Number
*
Telegram Handle
Nature of Operations
NAICS
Year Incorporated
Company Website
Company Type
*
Company Type
A
Privately Held
Company Type
B
Publicly Traded
Company Type
C
Not-For-Profit
Company Type
D
Financial Institution
Are you working with an insurance broker?
*
Are you working with an insurance broker?
Yes
No
Broker's Email
Has the Applicant been involved with, negotiated, attempted or transacted any merger, acquisition, asset sale or divestment in the past (18) eighteen months where
such a merger, acquisition, asset sale or divestment involved more than (25%) twenty-five percent of the total assets or securities of the Applicant?
*
Has the Applicant been involved with, negotiated, attempted or transacted any merger, acquisition, asset sale or divestment in the past (18) eighteen months where such a merger, acquisition, asset sale or divestment involved more than (25%) twenty-five percent of the total assets or securities of the Applicant?
A
Yes
B
No
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