ExecutivePerils
11845 West Olympic Boulevard • Suite 750• Los Angeles •CA • 90064
T:3104449333 • F:3104449355 • Web: CA Lic# 0E36308
dba: Executive Perils Insurance Services
APPLICATION FOR COMPREHENSIVE INTELLECTUAL PROPERTY INSURANCE POLICY
PLEASE READ THE ENTIRE APPLICATION CAREFULLY BEFORE SIGNING
I APPLICANT INFORMATION
1.
Name of Applicant (please include DBA’s)Address:
Mailing Address if different from above:
Owner/Contact Name and Title:
Phone No. : / Fax No.:
E Mail Address:
Number of locations or branch offices including the Main Office:
**Please Note: Applicant will be referred to as “You” in the rest of this application**
2. / Please describe the nature of your business:3. / How is Your business organized:
A.Individual Partnership Corporation
Other :B.Franchiser Franchisee Independent
Other :- Gross Sales:
U.S. Sales / Foreign Sales / Total Sales
a. Previous Year / $ / $ / $
b. Current Year / $ / $ / $
c. Next Year / $ / $ / $
5. Is your business primarily:
Retail Mostly retail/ some wholesale
Mostly wholesale/some retailExclusively wholesale
6. Who are the principal customers served by your business:Does your business involve “after market supply” or re-seller market (e.g., automotive replacement
parts, printer ink replacement, long distance telephone re-seller) YES NO
- How often do you use comparative advertising, (e.g. comparing your product to that of another) in
promoting/advertising your product or service?
Never Infrequently (once or twice a year) Frequently (more than twice per year)
Often (a consistent part of our advertising/marketing strategy.
- Do you rely heavily on “mailing list” or “client list” in the marketing or development of your business?
YES NO
If YES please give detail:9. Do any of the services you sell or provide include advertising or marketing for others?
YES NO
If YES please give detail:10. Do you contract for outside services on a regular basis: YES NO
If YES please indicate the services received:II PATENT INFORMATION
- Do you produce any products that currently have patents issued?YES NO
IF YES, please list and describe on Schedule A (Attached) those Patents, or Patents Pending, that you wish to have covered by this policy.
- Do you produce any products that currently have patents pending?YES NO
IF YES, Please list and describe on Schedule A (Attached) those Patents, or Patents Pending, that you wish to have covered by this policy.
3. During the last 5 years have any of Your patents been challenged ? YES NO
IF YES, Please supply detailed information regarding the challenge, the outcome of the challenge, and any
amounts paid by you or an insurer in settling the challenge:4. Are you currently aware of any threatened litigation or other challenges to the validity of any patent held by you, or patent pending by you? YES NO
IF YES Please provide full details:5. Do you have a patent attorney on staff with full time responsibilities for filing patents, giving advice about potential infringements and other intellectual property legal advice? YES NO
IF YES, Please provide the name and resume of attorney(s):6. Do you have an outside, independent law firm that regularly provides you patent and intellectual property legal advice? YES NO
IF YES, Please provide the name of the law firm its address and the attorney who is your contact?
Name:Address:
Contact:
7. Are you the licensee of any patents?YES NO
IF YES, Please specifically identify all licenses and sample copies of the licensing agreement.
8. Do you license patents that you own? YES NO
IF YES, Please provide details regarding the frequency of such licensing, the licenses outstanding and a
sample of your licensing agreements:9. During the last 5 years have you initiated any litigation/arbitration against another for violation of a patent you hold, or a patent that you have pending? YES NO
IF YES, Please provide full details, including the outcome of the litigation/arbitration, with estimate of the
cost and recovery amounts.- During the last 5 years have you made a claim against another for patent infringement that did not involve
litigation/arbitration, but was resolved by settlement or other means? YES NO
IF YES, Please provide full details, including the method of resolution and any monies paid by either you or the
other party.:11. Who are the inventors of the patents that you now hold?
Current Employee Former Employee Named Insured
Independent contractor Patent purchased Invention purchased
Other (Give Details):12. If former employee is the inventor, is the employee bound by any restrictive covenants regarding the invention, the patent, non-compete agreements? YES NO
IF YES, Please provide detail.13. Are any of your patents registered in foreign countries? YES NO
IF YES, Please list those patents and the countries where registered? Also provide the amount of sales or activity regarding your product or patent in the foreign countries where the patent is registered:III TRADEMARK/SERVICE MARK INFORMATION
1. Do you currently have any trademarks or service marks registered? YES NO
IF YES, please list and describe on Schedule B (Attached) those Trademarks/Service marks, that you wish to have covered by this policy:
2. During the last 5 years have any of your trademarks/service marks been challenged ? YES NO
IF YES, Please supply detailed information regarding the challenge, the outcome of the challenge, and any
amounts paid by you or an insurer in settling the challenge:- Are you currently aware of any threatened litigation or other challenges to the validity of any trademark/service mark that you are using? IF YES, Please provide full details: YES NO
4. During the last 5 years have you initiated any litigation/arbitration against another for infringement of a trademark/service mark you hold? YES NO
IF YES, Please provide full details, including the outcome of the litigation/arbitration, with estimate of the cost
and recovery amounts?5. During the last 5 years have you made a claim against another for trademark/service mark infringement that did not involve litigation/arbitration, but was resolved by settlement or other means? YES NO
IF YES, Please provide details, including the details of the resolution and method of resolution:
6. Are any of your trademarks/Service marks registered in foreign countries? YES NO
IF YES, Please list those trademarks/Service marks and the countries where registered? Also provide the amount of sales or activity regarding your trademark/service mark in the foreign countries where the trademark/service mark is registered
IV COPYRIGHT INFORMATION
1. Do you regularly register any original materials for copyright protection? YES NO
IF YES, Please provide an estimate of the number of copyright filings that you make in a year:
2. During the last 5 years have any of your copyrights been challenged ? YES NO
IF YES, Please supply detailed information regarding the challenge, the outcome of the challenge, and any
amounts paid by you or an insurer in settling the challenge:- Are you currently aware of any threatened litigation or other challenges to the validity of any
copyright that you hold? IF YES, Please provide full details YES NO
4. During the last 5 years have you initiated any litigation/arbitration against another for infringement of a copyright that you hold? YES NO
IF YES, Please provide full details, including the outcome of the litigation/arbitration, with estimate of the cost
and recovery amounts.- During the last 5 years have you made a claim against another for a copyright infringement that did not involve litigation/arbitration, but was resolved by settlement or other means? YES NO
IF YES, Please provide details, including the details of the resolution and method of resolution:
V TRADE SECRET COVERAGE
1. Do you have any confidential materials that you would classify as trade secrets? YES NO
IF YES please identify the nature of the trade secret(s):2. Please identify the precautions/safeguards that are in place to protect the above trade secrets:
3. Do your key employees/and those with access to trade secrets have written non-disclosure/non-compete agreements? YES NO
IF YES, please provide a copy of the agreements. Included Not Included
4. Have any employees with knowledge of your trade secrets left your employ within the last two years? YES NO
IF YES, please provide the details of the termination, whether any non-disclosure/non-compete agreements are in effect, length of time agreements are in effect, whether employee in now working with a competitor:
5. During the last 5 years have you been involved in litigation or a claim where someone accused You of taking or interfering with their trade secret(s). YES NO
IF YES, Please supply detailed information regarding the incident, the outcome, and any amounts paid to resolve the matter:
6. Are you currently aware of any threatened litigation against you involving the trade secrets of another party? YES NO
IF YES, Please provide full details:7. During the last 5 years have you initiated any litigation/arbitration against another for taking or interfering with a trade secret of yours? YES NO
IF YES, Please provide full details, including the outcome of the litigation/arbitration, with estimate of the cost
and recovery amounts:8. During the last 5 years have you made a claim against another for taking or interfering with a trade secret of yours that did not involve litigation/arbitration, but was resolved by settlement or other means? YES NO
IF YES, Please provide details, including the details of the resolution and method of resolution;
VI LIMIT OF LIABILITY AND CO-INSURANCE OPTIONS
1. Limit of liability Desired:(Claims made and Reported Coverage):
$500,000/$500,000 $750,000/$750,000
$1,000,000/$1,000,000 $2,000,000/$2,000,000.
Other. Please indicate limits desired:
2.Co-Insurance Percentages Desired: Note: Coinsurance is only applicable to Prosecution coverage.
20%25% 30% Other, please indicate:
VIILOSS INFORMATION
1.Does any director, officer, employee or partner of the Applicant have knowledge or information of any kind that would lead a reasonable person in the insured’s position to believe that a claim for infringement of any of the intellectual property right of another, whether valid or not, may be brought against the insured?
YES NO
If “Yes”, please explain on a separate sheet.
2.During the Last five (5) years, has any claim been made against the Applicant or any director, officer, employee or partner of the Applicant for any occurrences alleging the infringement of any intellectual property rights of another person or entity?
YES NO
If “Yes”, please explain on a separate sheet.
3.Is any director, officer, employee or partner of the Applicant have knowledge or information of any kind of any existing or potential infringement of any intellectual property right of the insured (whether said right is the subject of this insurance or not) that is being infringed by another which could give rise to a claim by the insured against the infringing entity?
YES NO
If “Yes”, please explain on a separate sheet.
THANK YOU FOR THE TIME SPENT IN COMPLETING THIS APPLICATION.
PLEASE READ THE FOLLOWING CAREFULLY AND SIGN BELOW WHERE INDICATED, IF A POLICY IS ISSUED, THE SIGNED APPLICATION WILL BE ATTACHED TO THE POLICY. PLEASE MAKE SURE EVERY QUESTION IS ANSWERED. UNANSWERED QUESTIONS WILL CAUSE THE RETURN OF THE APPLICATION AND DELAY YOUR COVERAGE.
THIS APPLICATION DOES NOT BIND THE APPLICANT TO BUY, OR THE COMPANY TO ISSUE, THE INSURANCE, BUT IT IS AGREED THAT THIS FORM SHALL BE THE BASIS OF THE CONTRACT AND SHOULD A POLICY BE ISSUED, IT WILL BE ATTACHED TO AND MADE A PART OF THE POLICY. THE UNDERSIGNED APPLICANT DECLARES THAT THE STATEMENTS SET FORTH IN THIS APPLICATION ARE TRUE. THE APPLICANT FURTHER DECLARES THAT IF THE INFORMATION SUPPLIED ON THIS APPLICATION CHANGES BETWEEN THE DATE OF THIS APPLICATION AND THE TIME WHEN THE POLICY IS ISSUED, THE APPLICANT WILL IMMEDIATELY NOTIFY THE COMPANY OF SUCH CHANGES, AND THE COMPANY MAY WITHDRAW OR MODIFY ANY OUTSTANDING QUOTATIONS AND/OR AUTHORIZATIONS OR AGREEMENTS TO BIND THIS INSURANCE.
WARRANTY: (PLEASE READ CAREFULLY)
Each director, officer, partner or official of the Named insured is unaware of any potential claim by the Named Insured that, in any way, involves the interference or violation of the intellectual property rights of the Named Insured and, at the current time, there is no intent and no known reason to prosecute a claim against another party for the violation of any intellectual property right of the Named Insured, whether or not said right is the subject of this insurance. It is further warranted that no officer, director, partner or official of the Named Insured is aware of any violation by the Named Insured of the Intellectual Property Rights of another party.
The signatory below further warrants that he/she has been authorized on behalf of the applicant(s) to make representations contained herein, and that the information contained herein is true to the best of his or her knowledge and shall become the basis of the policy of insurance for which application is hereby made and is deemed incorporated therein if Evanston Insurance Company evidences its acceptance of this application by issuance of a policy or by any other evidence of insurance.
Signature / Date:Name: / Title:
Signing this form does not bind the applicant or Evanston Insurance Company to complete the contract of insurance. This application must be signed and dated in order to be considered for quotation purposes. The soliciting insurance broker must be licensed in your state as a surplus lines broker.
Surplus Lines Broker InformationDate Submitted:
Agency:Address:
Surplus Lines License No.: / State:
Underwriting Manager:
ExecutivePerils
11845 West Olympic Boulevard • Suite 795•Los Angeles•CA • 90064
T:3104449333 • F:3104449355 • Web: CA Lic# 0E36308
dba: Executive Perils Insurance Services
SCHEDULE A
LIST OF PATENTS FOR COVERAGE
Patent NumberDescriptionDate Patent Issued
SCHEDULE B
LIST OF TRADEMARKS/SERVICE MARKS FOR COVERAGE
Trademark/Service mark DescriptionDate Registered
SCHEDULE C
MAJOR COPYRIGHTS HELD
Copyrights Registered Previous Year:Copyrights Registered Current Year:
Copyrights Registered Next Year(Estimate):
1
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