Test Form

Employment Practices Liability Insurance

NOTICE

LIABILITY COVERAGE PARTS PROVIDE CLAIMS MADE COVERAGE. EXCEPT AS OTHERWISE SPECIFIED: COVERAGE APPLIES ONLY TO A CLAIM FIRST MADE AGAINST THE INSUREDS DURING THE POLICY PERIOD AND WHICH HAS BEEN REPORTED TO THE INSURER IN ACCORDANCE WITH THE APPLICABLE NOTICE PROVISIONS. COVERAGE IS SUBJECT TO THE INSURED’S PAYMENT OF THE APPLICABLE RETENTION. PAYMENTS OF DEFENSE COSTS ARE SUBJECT TO, REDUCE, AND MAY COMPLETELY EXHAUST THE AVAILABLE LIMIT OF LIABILITY. PLEASE READ THE POLICY CAREFULLY AND DISCUSS THE COVERAGE WITH YOUR INSURANCE AGENT OR BROKER.

GENERAL INFORMATION

Name of Applicant Company:(Required)

(Together with any subsidiaries for whom this policy is intended, hereinafter, “Applicant(s).”)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Nature of Business and SIC or NAIC Code:(Required)

Year of Incorporation:(Required)

COVERAGE REQUESTED

Please check the boxes below to indicate which coverage is being requested.(Required)

Directors, Officers & Entity Liability

Employment Practices Liability

Fiduciary Liability

Crime

Kidnap & Ransom/Extortion

CyberChoice Premier

Directors, Officers & Entity Liability

Limits Requested

Please enter a number greater than or equal to 0.

Currently Purchased

Yes

Date Coverage First Purchased

Current Limits

Please enter a number greater than or equal to 0.

Current Retention

Please enter a number greater than or equal to 0.

Current Carrier and Premium

Employment Practices Liability

Limits Requested

Please enter a number greater than or equal to 0.

Currently Purchased

Yes

Date Coverage First Purchased

Current Limits

Please enter a number greater than or equal to 0.

Current Retention

Please enter a number greater than or equal to 0.

Current Carrier and Premium

Fiduciary Liability

Limits Requested

Please enter a number greater than or equal to 0.

Currently Purchased

Yes

Date Coverage First Purchased

Current Limits

Please enter a number greater than or equal to 0.

Current Retention

Please enter a number greater than or equal to 0.

Current Carrier and Premium

Crime

Limits Requested

Please enter a number greater than or equal to 0.

Currently Purchased

Yes

Date Coverage First Purchased

Current Limits

Please enter a number greater than or equal to 0.

Current Retention

Please enter a number greater than or equal to 0.

Current Carrier and Premium

Kidnap & Ransom/Extortion

Limits Requested

Please enter a number greater than or equal to 0.

Currently Purchased

Yes

Date Coverage First Purchased

Current Limits

Please enter a number greater than or equal to 0.

Current Retention

Please enter a number greater than or equal to 0.

Current Carrier and Premium

CyberChoice Premier

Limits Requested

Please enter a number greater than or equal to 0.

Currently Purchased

Yes

Date Coverage First Purchased

Current Limits

Please enter a number greater than or equal to 0.

Current Retention

Please enter a number greater than or equal to 0.

Current Carrier and Premium

PRIOR KNOWLEDGE

The following question must be answered if the Applicants are requesting higher limits than current limits, including requesting coverage which is not currently purchased.

Does an Applicant or any natural person for whom insurance is intended have any knowledge or information of any error, misstatement, misleading statement, act, omission, neglect, breach of duty or other matter that may give rise to a claim?

Yes

If “YES,” provide full details

IT IS AGREED THAT IF ANY SUCH KNOWLEDGE OR INFORMATION EXISTS, ANY CLAIM BASED ON, ARISING FROM, OR IN ANY WAY RELATING TO SUCH ERROR, MISSTATEMENT, MISLEADING STATEMENT, ACT, OMISSION, NEGLECT, BREACH OF DUTY OR OTHER MATTER OF WHICH THERE IS KNOWLEDGE OR INFORMATION SHALL BE EXCLUDED FROM COVERAGE REQUESTED. HOWEVER, THIS EXCLUSION SHALL APPLY UNDER A SPECIFIC COVERAGE PART ONLY TO THE EXTENT THAT THE “LIMITS REQUESTED” ARE HIGHER THAN THE “CURRENT LIMTS” PURCHASED FOR THAT COVERAGE PART.

APPLICANT INFORMATION

Does the Applicant Company have any subsidiaries?

Yes

List any subsidiaries of the Applicant Company below. Add rows for additional entries if needed.

NAME

NATURE OF BUSINESS

DATE CREATED OR ACQUIRED

% OWNED BY APPLICANT

STATE/COUNTRY

Total number of current US based employees:

Please enter a number greater than or equal to 0.

Total number of current US locations:

Please enter a number greater than or equal to 0.

Total number of current Foreign based employees:

Please enter a number greater than or equal to 0.

Total number of current Foreign locations?

Please enter a number greater than or equal to 0.

Has an Applicant experienced within the past 24 months, or does an Applicant anticipate in the next 12 months, any of the following events:

Merger, acquisition, sale of any assets or other similar transaction?

Yes

If the response is “YES”, please provide full details:

Any financial restructuring, reorganization or filing for bankruptcy?

Yes

If the response is “YES”, please provide full details:

Any downsizing, layoffs, reduction in force, plant or office closings?

Yes

If the response is “YES”, please provide full details:

Please provide the following based on the Applicants’ most recent fiscal year end (“FYE”) and the year prior.

Current Assets

Most Recent Fiscal Year End

Year Prior to Most Recent Fiscal Year End

Goodwill

Most Recent Fiscal Year End

Year Prior to Most Recent Fiscal Year End

Total Assets

Most Recent Fiscal Year End

Year Prior to Most Recent Fiscal Year End

Current Liabilities

Most Recent Fiscal Year End

Year Prior to Most Recent Fiscal Year End

Long Term Debt

Most Recent Fiscal Year End

Year Prior to Most Recent Fiscal Year End

Total Liabilities

Most Recent Fiscal Year End

Year Prior to Most Recent Fiscal Year End

Retained Earnings

Most Recent Fiscal Year End

Year Prior to Most Recent Fiscal Year End

Shareholder Equity

Most Recent Fiscal Year End

Year Prior to Most Recent Fiscal Year End

Total Revenues

Most Recent Fiscal Year End

Year Prior to Most Recent Fiscal Year End

Earnings before interest and Taxes

Most Recent Fiscal Year End

Year Prior to Most Recent Fiscal Year End

Net income after taxes

Most Recent Fiscal Year End

Year Prior to Most Recent Fiscal Year End

Interest Expense

Most Recent Fiscal Year End

Year Prior to Most Recent Fiscal Year End

Cash flow from Operations

Most Recent Fiscal Year End

Year Prior to Most Recent Fiscal Year End

DIRECTORS, OFFICERS & ENTITY LIABILITY COVERAGE PART

List all shareholders for all classes of stock or other ownership of the Applicant Company.

Total number of shareholders

Please enter a number from 0 to 100.

#1 Shareholder

Name

Percentage Held

Please enter a number from 0 to 100.

Entity Type (if not an individual)

Is the individual a Director/Officer, or does the entity have direct representation on the board of directors?

Yes

#2 Shareholder

Name

Percentage Held

Please enter a number from 0 to 100.

Entity Type (if not an individual)

Is the individual a Director/Officer, or does the entity have direct representation on the board of directors?

Yes

#3 Shareholder

Name

Percentage Held

Please enter a number from 0 to 100.

Entity Type (if not an individual)

Is the individual a Director/Officer, or does the entity have direct representation on the board of directors?

Yes

#4 Shareholder

Name

Percentage Held

Please enter a number from 0 to 100.

Entity Type (if not an individual)

Is the individual a Director/Officer, or does the entity have direct representation on the board of directors?

Yes

#5 Shareholder

Name

Percentage Held

Please enter a number from 0 to 100.

Entity Type (if not an individual)

Is the individual a Director/Officer, or does the entity have direct representation on the board of directors?

Yes

#6 Shareholder

Name

Percentage Held

Please enter a number from 0 to 100.

Entity Type (if not an individual)

Is the individual a Director/Officer, or does the entity have direct representation on the board of directors?

Yes

#7 Shareholder

Name

Percentage Held

Please enter a number from 0 to 100.

Entity Type (if not an individual)

Is the individual a Director/Officer, or does the entity have direct representation on the board of directors?

Yes

#8 Shareholder

Name

Percentage Held

Please enter a number from 0 to 100.

Entity Type (if not an individual)

Is the individual a Director/Officer, or does the entity have direct representation on the board of directors?

Yes

Pleaes include detailed information for the remaining shareholders

Within the past 24 months or the next 12 months, has an Applicant completed or does an Applicant anticipate completing any public or private offering of securities (including, but not limited to, IPO, Secondary Exchanges, or Crowd Funding/Crowd Financing)?

Yes

If “YES”, please provide full details

Is an Applicant currently, or has an Applicant been in the past 12 months, in breach or violation of any debt covenant or loan agreement or any other material contractual obligation?

Yes

If “YES”, please provide full details

Has an Applicant, or any natural person for whom this insurance is intended, been involved in:

Any antitrust, copyright or patent litigation?

Yes

If “YES”, please provide full details

Any civil or criminal action or administrative proceeding alleging a violation of any federal or state security law or regulation?

Yes

If “YES”, please provide full details

Any representative actions, class actions or derivative suits?

Yes

If “YES”, please provide full details

Any other litigation?

Yes

If “YES”, please provide full details

PLEASE PROVIDE THE FOLLOWING INFORMATION: Most recent audited Financial Statement and CPA opinion

Max. file size: 256 MB.

EMPLOYMENT PRACTICES LIABILITY COVERAGE PART

Please list the following information based on the Applicants’ current facts as of today and those facts of one year ago:

Non-Union Full Time US Employees (including interns)

Currently

Please enter a number greater than or equal to 0.

1 Year Ago

Please enter a number greater than or equal to 0.

Non-Union Part Time US Employees (including interns)

Currently

Please enter a number greater than or equal to 0.

1 Year Ago

Please enter a number greater than or equal to 0.

Independent Contractors

Currently

Please enter a number greater than or equal to 0.

1 Year Ago

Please enter a number greater than or equal to 0.

Union Employees

1 Year Ago

Please enter a number greater than or equal to 0.

Currently

Please enter a number greater than or equal to 0.

Foreign Based Employees

1 Year Ago

Please enter a number greater than or equal to 0.

Currently

Please enter a number greater than or equal to 0.

Foreign Based Employees

1 Year Ago

Please enter a number greater than or equal to 0.

Currently

Please enter a number greater than or equal to 0.

Foreign Based Employees

1 Year Ago

Please enter a number greater than or equal to 0.

Currently

Please enter a number greater than or equal to 0.

How many employees have total compensation (including any bonus and commissions) above $200,000 annually?

Please enter a number greater than or equal to 0.

Section Break

Please list the number of Involuntary Terminations:

Within Last 12 months:

Please enter a number greater than or equal to 0.

Within Last 24 months:

Please enter a number greater than or equal to 0.

Please list the number of Layoffs:

Within Last 12 months:

Please enter a number greater than or equal to 0.

Within Last 24 months:

Please enter a number greater than or equal to 0.

Was severance available to all affected?

N/A

Yes

If “NO”, please provide full details:

Did all severance recipients sign a release?

N/A

Yes

If “NO”, please provide full details:

Section Break

Is an employee handbook distributed to all employees?

Yes

Do you have have written procedures in place regarding Sexual Harassment?

Yes

Do you have have written procedures in place regarding Discrimination?

Yes

Do the Applicants have a stand-alone Human Resources Department?

Yes

Do the Applicants review all terminations with Legal Counsel?

Yes

Do the Applicants employ any outside employment risk management services?

Yes

Do the Applicants require new employees to agree to arbitrate employment disputes?

Yes

Do the Applicants require new employees to sign class action waivers?

Yes

Has an Applicant experienced any complaints, charges or hearings involving:

Any Civil complaint as respects Employment Practices Liability, including any Class or Multi- Claimant Action?

Yes

Any Federal, State or Local Government agency as respects Employment Practices Liability?

Yes

If “YES”, please provide full details:

FIDUCIARY LIABILITY COVERAGE PART

For each plan to be covered, please enter the following:

Plan #1

Plan Name

Plan Type

# Of Participants

Please enter a number greater than or equal to 0.

Plan Assets (Current Year)

Please enter a number greater than or equal to 0.

Plan Status

Plan #2

Plan Name

Plan Type

# Of Participants

Please enter a number greater than or equal to 0.

Plan Assets (Current Year)

Please enter a number greater than or equal to 0.

Plan Status

Plan #3

Plan Name

Plan Type

# Of Participants

Please enter a number greater than or equal to 0.

Plan Assets (Current Year)

Please enter a number greater than or equal to 0.

Plan Status

Has an Applicant, any plan, or plan fiduciary: been accused or found guilty of a breach of fiduciary duty or violation of ERISA?

Yes

If the response is “YES”, please provide full details:

Has an Applicant, any plan, or plan fiduciary: been investigated by the DOL, IRS or any other regulatory agency in the past 2 years?

Yes

If the response is “YES”, please provide full details:

Has an Applicant, any plan, or plan fiduciary: had any other litigation against any Plan or Plan Fiduciary?

Yes

If the response is “YES”, please provide full details:

Does any plan hold or provide the option to invest in the securities of an Applicant?

Yes

If the response is “YES”, please provide full details:

Within the past 24 months have there been, or does an Applicant anticipate in the coming 12 months that there will be, any reductions in benefits?

Yes

If the response is “YES”, please provide full details:

Get the Right Coverage

As a lawyer, even small details of your work can have significant ramifications. Even if allegations of legal malpractice are untrue, the requirements of defending yourself could have catastrophic consequences for your finances and future.

We’re here to help. At L Squared Insurance, our agents have the experience and expertise to help lawyers and their firms assess and address their coverage needs with optimal policies.

Test Form

Employment Practices Liability Insurance

NOTICE

GENERAL INFORMATION

COVERAGE REQUESTED

PRIOR KNOWLEDGE

APPLICANT INFORMATION

DIRECTORS, OFFICERS & ENTITY LIABILITY COVERAGE PART

EMPLOYMENT PRACTICES LIABILITY COVERAGE PART

Section Break

Section Break

FIDUCIARY LIABILITY COVERAGE PART

Get the Right Coverage

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