REQUEST FOR A NON-BINDING PREMIUM INDICATION
PRIVATE CHOICE ENCORE FOR TEC POLICY

This non-binding premium indication is open to Corporations and Limited Liability Companies with less than 350MM in revenue whose securities are not offered to the public. Financial Institutions Companies are not eligible for a non-binding indication under this worksheet. Publicly traded companies, Financial Institutions and Technology companies must complete a long form application.
 
General Information
Proposed Insured Name
Address
City
State Zip
Description of Operations
Do you currently carry D&O or EPLI or Fiduciary coverage?   
 D&O   EPLI   Fiduciary 
As of the end of the Firm's last fiscal year:

$   Total Assets
$   Total Liabilities
$   Gross Revenues
$   Net Income Before Taxes
 
Agent Information
Agent Name
Agency Name
Agent City
State Zip
Telephone
Fax
Email
 
D&O Information
  Total Number of Shareholders
  % of Shares Owned by D&O
 
EPLI Information
  Total Number of Full Time Employees
  Total Number of Part Time Employees
  Total Number of Employees in TX, MI or CA
In the next 12 months, does the Proposed Insured anticipate or has the Proposed Insured completed in the last year any layoffs?     
 Yes   No
Do You Maintain and Distribute an Employee Handbook?    
 Yes   No
 
Fiduciary Information (optional)
Type
of Plan		 Plan
Name		 Total
Assets		 Trustee/Plan
Administrator
Type of Plan:
DB = Defined Benefit    DC = Defined Contribution    W = Welfare Benefit    O = Other
 
Claims Information
During the past three years has this firm been involved in any D&O, EPLI or Fiduciary Liability related litigation?     Yes   No
 
Files To Attach (optional)
Only Adobe PDF, MS-Word, MS-Excel, and/or text files may be attached.
 
 
Disclaimer
THIS IN NOT AN APPLICATION FOR INSURANCE! THIS DOCUMENT PROVIDES BASIC INFORMATION FOR THE PURPOSE OF OBTAINING A NON-BINDING PREMIUM INDICATION. SUCH INDICATION IS NOT BINDING ON THE HARTFORD FIRE INSURANCE COMPANY AND ITS AFFILIATES AND SUBSIDIARIES ("THE HARTFORD") AND DOES NOT OBLIGATE THE HARTFORD TO ISSUE AN INSURANCE POLICY. TO OBTAIN AN ACTUAL QUOTE FOR INSURANCE, IT IS NECESSARY TO SUBMIT A PROPERLY COMPLETED APPLICATION AND ALL OF THE SUPPORTING DOCUMENTATION REQUESTED THEREIN. THE TERMS OF ANY QUOTE MAY VARY CONSIDERABLY FROM ANY INDICATIONS WHICH WERE PREVIOUS RECEIVED.