Commercial Liability EO

By Gilbert Kelley,2014-05-19 14:02
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Do your quality control procedures or initiatives include the following: Written and formalized quality control program? ? Yes ? No, ? N/A


    Chubb Insurance Company of Canada Commercial Liability Insurance

    Errors and Omissions

    Some sections of the application may not apply to your organization. Where this is the case, please indicate “Not applicable” (N/A).

Applicant Information

Applicant Name: (Include names of all subsidiaries or affiliated companies to be insured.)

Requested Effective Date: / / / / Requested Retroactive Date:


    Errors & Omissions: 1. Limit Of Insurance:

     $1 million $2 million $5 million $10 million Other: $

    2. Deductible

    (each claim): $10,000 $25,000 $50,000 $100,000 $250,000 Other: $

     3. Worldwide Revenue, including Licensing Fees:

     Canada USA Other Foreign Total

     Prior Year: $ $ $ $

     Current Year: $ $ $ $

     Estimated Next Year: $ $ $ $

     4. Financials

     Over the past four years, how many years did you post a positive net income? 0 1 2 3 4

     5. Mergers or Acquisitions or Divestitures

     Have you sold, acquired or merged with any companies during the past three years? Yes No

     If yes, please detail any liabilities you retained or purchased:


     1. Describe your business operations:

     2. Describe your products and services as follows:

     Percentage of

    Type of Product or Service Annual Revenue Application of that Product or Service




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    3. What would be the most likely financial and business impact on your customers from a performance failure of any of your

    products or services?

     No disruption Minor or delayed Major or immediate

    4. In your opinion, what would be the largest financial and business impact on your customers for a performance failure of any

    of your products or services? Indicate dollar amount and explain in detail.


    Please provide copies of your standard and largest sales, service and licence contracts, agreements, or purchase orders.

    1. What type of contracts or agreements do you utilize to conduct your product and service transactions:

     Standard and written? % of the time Custom contract? % of the time

     Purchase order? % of the time Verbal contract? % of the time

     Invoice? % of the time Other? % of the time

    $ 2. What is the value of your average contract, agreement, or purchase order?

    $ 3. What is the value of your largest contract, agreement, or purchase order?

    4. Do you negotiate contracts or agreements in which you accept liability for

    consequential damages, except Intellectual Property? Yes No % of the time 5. Do all your contracts or agreements limit your liability to the cost of your

    product of service? Yes No 6. Do you perform legal review of all standard contracts and marketing

    materials prior to release? Yes No


1. Describe below what work is subcontracted:

     Percentage of Work

    Type of Subcontracted Work Subcontracted





     % 2. Do you have written contracts with your subcontractors? Yes No

    If Yes, are you and your clients indemnified for damages caused by the subcontractor? Yes No



    1. Do your quality control procedures or initiatives include the following:

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     a) Written and formalized quality control program? Yes No N/A

     b) Formal customer evaluation and acceptance procedures? Yes No N/A

     c) Formal product recall/post sale correction action plan? Yes No N/A

     d) Quality control program for subcontracted work? Yes No N/A

     e) Written logs for customer complaints of problems or downtime? Yes No N/A 2. Describe your product or service delivery and formalized customer acceptance procedures:

     Percentage of

    Annual Revenue Customer Acceptance

     Design only % Yes No

     Design and manufacture % Yes No

     Manufacture to customer specifications % Yes No

    3. What are your typical customer complaints or problems?

4. Describe your dispute resolution process:


1. In the past three years, have you or your subcontractors experienced any of the following:

     a) Product recalls or post sale corrective actions? Yes No

     b) Delayed or past due contracts? Yes No

     c) Allegations that the product or service did not meet the customer’s performance expectations? Yes No

     d) Allegations that the product or service did not comply with your warranties or representations? Yes No

     If yes, please explain:

    2. Are you aware of any act, error or omission, unresolved contract dispute or any other circumstance that

    may reasonably be expected to result in a claim? Yes No

     Please explain:

    3. Within the past three years, have you sued any customers for non-payment of contracts? Yes No

     If yes, please explain:

    4. List and provide details on any suits, potential suits, complaint letters, disputes or any other circumstances alleging non-

    performance of contract or non-performance of your products or services:

5. Has any company ever declined to write, cancelled or non-renewed Errors Or Omissions/Professional

    Liability coverage for you? Yes No 6. Do you currently purchase Errors Or Omissions/Professional Liability coverage? Yes No

     Carrier Name: Limit: $

     Effective Date: Deductible: $

     Premium: $ Retroactive Date:

Applicant Acknowledgement

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Information or data contained in or submitted in connection with this application does not constitute notice of an

    occurrence, wrongful act, claim, suit or other circumstance and does not satisfy any of the reporting notification or other

    provisions of any policy. All such notices must be given separately in accordance with the applicable policy conditions.

For the purposes of this application, the undersigned officer of all person(s) and entity(ies) proposed for this insurance

    declares and acknowledges that he/she has reviewed this application and the statements contained therein with his/her

    Chief Executive Officer, Chief Financial Officer, Chief Operating Officer or their equivalents, and that to the best of their

    knowledge and belief, after reasonable inquiry, the statements in this application, and in any attachments, are true and

    complete. Chubb is authorized to make any inquiry in connection with this application. Signing this application shall not

    constitute a binder or obligate Chubb to complete this insurance, but it is agreed this application shall be the basis upon

    which a policy may be issued.

If the statements in this application or in any attachment change materially before the effective date of any proposed

    policy, the applicant must notify Chubb, and Chubb may modify or withdraw any quotation.

You understand that the limit of liability under any policy to be issued in response hereto shall include both indemnity

    payments for claims and payment of claim adjustment expenses, as defined in the policy.

    Defence cost provisions Please note that the claim adjustment expense provision of the policy stipulates that the limits of liability may be completely exhausted by the cost of claim adjustment expenses. Any deductible or retention shall

    apply to claim adjustment expenses as well as indemnity. Please initial: _______________

     Date Signature Title

    NOTICE TO APPLICANT PLEASE READ CAREFULLY Any person who knowingly and with the intent to defraud any insurance company or other person, files an application for

    insurance or statement of claim containing any materially false information or conceals for the purpose of misleading,

    information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such

    person to criminal and civil penalties, including but not limited to fines, denial of insurance benefits, civil damages,

    criminal prosecution and confinement in prison.

    Submitted by:


    Phone: ( ) Fax: ( )


Chubb Commercial Liability E&O Application Page 4 of 4

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