REQUEST FOR A TEMPORARY AND CONDITIONAL QUOTE
PRIVATE CHOICE ENCORE POLICY

Quick Quote is available to Corporations and Limited Liability Companies with $350 million or less in revenue whose securities are not offered to the public. Publicly traded companies, Financial Institutions and Technology Companies are not eligible for a Quick Quote short form worksheet and must complete a long form application.
 
General Information (required)
Proposed Insured Name
Address
City
State Zip
 
Agent Information (required)
Agency Name
Address
Agent City
State Zip
Telephone
Fax
Email
Agent Name
 
Underwriting Information
Proposed Effective Date
Description of Operations
I want a quote for the following coverages:   
 D&O    EPLI    Fiduciary    Employee Dishonesty    Kidnap & Ransom 
Does the firm currently purchase any of the following coverages?    Yes   No
As of the end of the Firm's last fiscal year:

$   Total Assets
$   Total Liabilities
$   Gross Revenues
$   Net Income Before Taxes
     Total Employees (including full & part time & seasonal)
Does the firm have an Employee Stock Ownership Plan (ESOP)?    Yes   No
What is the total of Plan Assets for all benefit plans?   
Do directors, officers or other employees of this firm make trips outside of the United States and Canada?     Yes   No       
If yes, please list countries.
 
Claims Information
During the past three years has this firm had any claims, losses, litigation, or proceedings, whether or not insured that would fall within the scope of the following insurance; D&O, EPLI, Fiduciary Liability, Employee Dishonesty or Kidnap & Ransom.     Yes   No  Don't know  
 
Files To Attach (optional)
Only Adobe PDF, MS-Word, MS-Excel, and/or text files may be attached.
 
 
Disclaimer
THE INFORMATION PROVIDED BY THE APPLICANT IS SUBJECT TO UNDERWRITING REVIEW AND APPROVAL AND ANY OFFERS OF INSURANCE SHALL CONSTITUTE A TEMPORARY AND CONDITIONAL QUOTE THAT IS SUBJECT TO RECEIPT OF A SIGNED AND COMPLETED APPLICATION OF INSURANCE.