Agent Info:
Name : Denis Mehulic
License ID : 0L58079
Phone : (408) 674-3569
Email : [email protected]
Address : ste 201 1095, San Jose, California, 95136

Directors and Officers

  • Applicant
  • Business
  • Auditor
  • Shares
  • Policy
  • Losses
  • Coverage
  • Miscellaneous
  • Finish

Applicant

First Name *
Last Name *

Where should we send your quote?

Email *
Phone *

Please fill all the mandatory questions.

Business

Business Info

Business /​ Company Name *
Founding Date *
DBA (If Applicable)
FEIN # (If Applicable)
Organization Type
Business Address
Address *
City *
State *
Zip Code *
Type of Business *
Specify business *

Employees

Full-Time Employees
Part-Time Employees
Volunteers
Independent Contractors

Additionals

In the next 12 months (or during the past 24 months) is the Applicant contemplating (or has the Applicant completed or been in the process of completing) the following:
Please Explain
Please Explain
Please Explain
Please Explain
Please Explain
Please Explain
Please Explain
Please Explain
Describe all entities in which the Applicant’s ownership interest is 50% or greater or over which the Applicant has management control.
Please Explain

Please fill all the mandatory questions.

Auditor

Has The Applicant Changed Outside Auditors In The Last 3 Years?
Please Explain *
Have The Outside Auditors Stated There Are Material Weaknesses In The Applicant’s Systems Of Internal Controls?
Please Explain *
Has The Applicant Implemented All Material Recommendations Of The Auditor?
Please Explain *
Has Any Auditor Issued A “Going Concern” Opinion For The Applicant’s Financial Statements During The Past 3 Years?
Please Explain *
Scope of Financial Statement Preparation *

Please fill all the mandatory questions.

Shares

Authorized

Common
Preferred
Other

Outstanding

Common
Preferred
Other

Voting Shares Outstanding

Common
Preferred
Other

Voting Shares Owned by Directors and Officers

Direct and Beneficial

Common
Preferred
Other

Number of Voting Shareholders

Direct and Beneficial

Common
Preferred
Other

Individual 1

Individual Shareholders

Name *
Class of Security *
% Owned

Please fill all the mandatory questions.

Policy

Prior / Existing Carrier

Name of Carrier *
Expiring Limit *
Expiring Premium
Expiring Retention

Please fill all the mandatory questions.

Losses

Loss 1

Loss / Claim Details
Nature of Loss /​ Claim *
Date of Loss /​ Claim
Amount Paid for Defense *
Amount Sought Or Paid For Damages *
Details of Loss /​ Claim

Please fill all the mandatory questions.

Coverage

Requesting Limits

Requested Limit
Requested Retention
Requested Effective Date

Insurance Terms

Please fill all the mandatory questions.

Miscellaneous

Please fill all the mandatory questions.



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