Insurance Ethical Issues Form

INSURANCE ETHICAL ISSUES FORM

Purpose: This form documents known or alleged ethical issues involving the Insured and collects attestations, disclosures, and supporting information required by the insurer for coverage assessment, investigation, and underwriting. Completion of this form is a certification under penalty of law that the information supplied is true, complete and correct to the best of the applicant's knowledge.

1. Applicant / Insured Information

2. Policy Details

Policy Type (select all that apply):

Professional Liability    Errors & Omissions    Directors & Officers    Cyber Liability    Commercial General Liability    Other:

Policy Period: From to

Requested coverage components (select all that apply):

Defense Costs    Investigation Expenses    Indemnity for Penalties (where insurable)    Reputational Management / Crisis Response

3. Reported or Known Ethical Issues

Have you, any principal, or any entity proposed for coverage ever been alleged to have engaged in or been subject to any of the following? (Select all that apply and provide details below.)

Conflict of Interest    Fraud or Material Misrepresentation    Discrimination or Harassment
Confidentiality or Data Breach    Improper Commissions or Kickbacks    Claims Handling Misconduct
Regulatory Investigation or Enforcement    Other:

Have any of the above matters resulted in professional discipline, license suspension, civil judgment, administrative penalty, criminal charges, settlement or consent order?

Yes    No

4. Exclusions and Acknowledgements

The following represent common exclusions and material conditions. By initialing each item, you acknowledge awareness of the exclusion and the insurer's ability to rely upon it in underwriting or declination decisions.

I acknowledge that coverage generally excludes intentional wrongful acts, deliberate criminal misconduct, and knowingly fraudulent acts.

I acknowledge that matters known to the applicant prior to the policy inception are material and may be excluded from coverage.

I acknowledge that willful violation of statutes or fiduciary obligations is frequently excluded.

I acknowledge that intentional breaches of confidentiality that are not part of covered claims may be excluded.

5. Beneficiary / Third-Party Information (If applicable)

6. Documentation Checklist

Please indicate which documents are attached to this disclosure.

Incident Reports    Investigation Reports    Legal Filings
Settlement Documents    Other:

7. Declaration and Certification

I, the undersigned, declare that I am authorized to make this disclosure on behalf of the applicant and that the information provided in this Insurance Ethical Issues Form is true, correct and complete. I understand that failure to disclose material facts, or providing false or misleading statements, may constitute a material misrepresentation and may void coverage, prejudice any claim for coverage, or be grounds for rescission of the policy.

I authorize any person or entity to release to the insurer and its representatives any records or information requested in connection with this disclosure, including investigative, disciplinary, regulatory, employment and claims records. I understand that the insurer may use such information in evaluating underwriting, coverage and claims handling decisions.

I further acknowledge that the insurer may report findings of material ethical violations to appropriate regulatory authorities where required or permitted by law.

Certification: I certify that the statements made in this form are accurate and complete to the best of my knowledge.

8. Additional Comments

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