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

This non-binding premium indication is open to Corporations and Limited Liability Companies with less than $350 million in revenue whose securities are not offered to the public. Publicly traded companies, Financial Institutions and Technology 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 (required)
Proposed Insured Name
Address
City
State Zip
 
Agent Information (required)
Agency Name
Address
Agent City
State Zip
Telephone
Fax
Email
Agent Name
Proposed Effective Date
Description of Operations
 
Underwriting Information
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 Handbook?    Yes   No
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
THIS IS 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 THAT WERE PREVIOUSLY PROVIDED.