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ACORD Form 180 Errors and Omissions Section Instructions
 

 
ACORD 180 (1997/01) 1 of 14
Universal wording updates to improve clarity and intent were made to all FIG text for this form on 05/29/2009.
Section Name Field Name Field and/or Section Description
TITLE ACORD 180 (1997/01) Errors and Omissions Section, Electronic Products Manufacturers, Computer Services and Products The title of the form. ACORD 180, Errors and Omissions Section, Electronic Products Manufacturers, Computer Services and Products, is used to apply for electronic data processors, electronic products manufacturers, and computer services products E&O. It is not intended to be used with general manufacturing or general service risks. This form was designed to be used in conjunction with the Commercial Insurance Application - Applicant Information Section (ACORD 125). Please turn to the chapter on ACORD 125 for information on that form.
IDENTIFICATION SECTION Date Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY)
IDENTIFICATION SECTION Producer Enter text: The full name of the producer/agency.
IDENTIFICATION SECTION Enter text: The mailing address line one of the producer/agency.
IDENTIFICATION SECTION Enter text: The mailing address line two of the producer/agency.
IDENTIFICATION SECTION Enter text: The mailing address city name of the producer/agency.
IDENTIFICATION SECTION Enter code: The mailing address state or province code of the producer/agency.
IDENTIFICATION SECTION Enter code: The mailing address postal code of the producer/agency.
IDENTIFICATION SECTION Phone (A/C,No,Ext) Enter number: The producer's contact person's phone number. If applicable, include the area code and extension.
IDENTIFICATION SECTION Code Enter code: The identification code assigned to the producer (e.g. agency or brokerage firm) by the insurer.
IDENTIFICATION SECTION Subcode Enter code: The identification code assigned by the insurer to the sub-producer (e.g. person) within a producer's office (e.g. agency or brokerage).
IDENTIFICATION SECTION Agency Customer ID Enter identifier: The customer's identification number assigned by the producer (e.g. agency or brokerage).
IDENTIFICATION SECTION Applicant (First Named Insured) Enter text: The named insured(s) as it/they will appear on the policy declarations page.
IDENTIFICATION SECTION Proposed Effective Date Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence.

ACORD 180 (1997/01) 2 of 14

Section Name Field Name Field and/or Section Description
IDENTIFICATION SECTION Direct Bill Checkbox Check the box (if applicable): Indicates if the policy is to be direct billed.
IDENTIFICATION SECTION Agency Bill Checkbox Check the box (if applicable): Indicates if the policy is to be producer/agency billed.
Enter code: The payment plan for the policy (i.e., AN - Annual, MO - Monthly, QT -
IDENTIFICATION SECTION Payment Plan Quarterly, etc.).
Enter code: The audit term for policies that are subject to periodic audit. If the audit period
is known, enter the code; A - annual, S - semi-annual, Q - Quarterly, M - Monthly, O -
IDENTIFICATION SECTION Audit Other.
IDENTIFICATION SECTION For Company Use Only Enter text: This area is to be completed by the insurer.
Enter text: The description of any mergers or acquisitions by your company (including
IDENTIFICATION SECTION List all mergers or acquisitions subsidiaries) in the mandated number of years.
IDENTIFICATION SECTION List all joint ventures Enter text: The description of all joint ventures in which your company is a partner.
POLICY/COVERAGE
INFORMATION Transaction Type Claims Made Check the box (if applicable): Indicates the policy is on a claims made basis.
POLICY/COVERAGE
INFORMATION Transaction Type Occurrence Check the box (if applicable): Indicates the policy is on an occurrence basis.
Enter date: The retroactive date you are requesting for the policy being applied for. This is
POLICY/COVERAGE Transaction Type Proposed the proposed earliest date for which an occurrence could "trigger" coverage under a
INFORMATION Retroactive Date Claims Made policy.
POLICY/COVERAGE
INFORMATION Transaction Type Deductible Enter deductible: The deductible amount for the coverage.
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being
POLICY/COVERAGE referenced exactly as it appears on the policy, including prefix and suffix symbols. If
INFORMATION Transaction Type Expiring Pol # required for self-insurance, the self-insured license or contract number.
POLICY/COVERAGE
INFORMATION Limits of Liability Each Claim Enter limit: The limit amount for each claims.
POLICY/COVERAGE Limits of Liability Each
INFORMATION Occurrence Enter limit: The limit amount for each occurrence.
POLICY/COVERAGE
INFORMATION Limits of Liability Aggregate Enter limit: The aggregate limit amount.
POLICY/COVERAGE Limits of Liability Current Enter date: The retroactive date if the policy was issued on a Claims Made basis and
INFORMATION Retroactive Date there was a retroactive date.

ACORD 180 (1997/01) 3 of 14

Section Name Field Name Field and/or Section Description
POLICY/COVERAGE INFORMATION Retained Limit Enter limit: The retained limit amount.
POLICY/COVERAGE INFORMATION Retained Limit - Defense Included Within Limit Yes Check the box (if applicable): Indicates that defense costs are included within the limit.
POLICY/COVERAGE INFORMATION Retained Limit - Defense Included Within Limit No Check the box (if applicable): Indicates that defense costs are not included within the limit.
POLICY/COVERAGE INFORMATION Retained Limit - First Dollar Defense Yes Check the box (if applicable): Indicates that first dollar defense coverage is requested.
POLICY/COVERAGE INFORMATION Retained Limit - First Dollar Defense No Check the box (if applicable): Indicates that first dollar defense coverage is not requested.
PRODUCTS AND SERVICES Fiscal Year Begins Enter date: The date the fiscal year begins.
PRODUCTS AND SERVICES Last Fiscal Year Domestic Enter amount: The domestic sales amount for the last fiscal year.
PRODUCTS AND SERVICES Last Fiscal Year Foreign Enter amount: The foreign sales amount for the last fiscal year.
PRODUCTS AND SERVICES Last Fiscal Year Total Enter amount: The total sales amount for the last fiscal year.
PRODUCTS AND SERVICES Current Fiscal Year Domestic Enter amount: The domestic sales amount for the current fiscal year.
PRODUCTS AND SERVICES Current Fiscal Year Foreign Enter amount: The foreign sales amount for the current fiscal year.
PRODUCTS AND SERVICES Current Fiscal Year Total Enter amount: The total sales amount for the current fiscal year.
PRODUCTS AND SERVICES Next Fiscal Year Domestic Enter amount: The domestic sales amount for the next fiscal year.
PRODUCTS AND SERVICES Next Fiscal Year Foreign Enter amount: The foreign sales amount for the next fiscal year.
PRODUCTS AND SERVICES Next Fiscal Year Total Enter amount: The total sales amount for the next fiscal year.
PRODUCTS AND SERVICES Product Line One Enter text: The description of the product line or service provided.
PRODUCTS AND SERVICES Sales Amount 1 Enter amount: The amount of sales for the product or service.
PRODUCTS AND SERVICES Product Line Two Enter text: The description of the product line or service provided.

ACORD 180 (1997/01) 4 of 14

Section Name Field Name Field and/or Section Description
PRODUCTS AND SERVICES Sales Amount 2 Enter amount: The amount of sales for the product or service.
PRODUCTS AND SERVICES Product Line Three Enter text: The description of the product line or service provided.
PRODUCTS AND SERVICES Sales Amount 3 Enter amount: The amount of sales for the product or service.
PRODUCTS AND SERVICES Product Line Four Enter text: The description of the product line or service provided.
PRODUCTS AND SERVICES Sales Amount 4 Enter amount: The amount of sales for the product or service.
PRODUCTS AND SERVICES Product Line Five Enter text: The description of the product line or service provided.
PRODUCTS AND SERVICES Sales Amount 5 Enter amount: The amount of sales for the product or service.
PRODUCTS AND SERVICES Product Line Six Enter text: The description of the product line or service provided.
PRODUCTS AND SERVICES Sales Amount 6 Enter amount: The amount of sales for the product or service.
PRODUCTS AND SERVICES Product Line Seven Enter text: The description of the product line or service provided.
PRODUCTS AND SERVICES Sales Amount 7 Enter amount: The amount of sales for the product or service.
PRODUCTS AND SERVICES Product Line Eight Enter text: The description of the product line or service provided.
PRODUCTS AND SERVICES Sales Amount 8 Enter amount: The amount of sales for the product or service.
PRODUCTS AND SERVICES Product Line Nine Enter text: The description of the product line or service provided.
PRODUCTS AND SERVICES Sales Amount 9 Enter amount: The amount of sales for the product or service.
PRODUCTS AND SERVICES Product Line Ten Enter text: The description of the product line or service provided.
PRODUCTS AND SERVICES Sales Amount 10 Enter amount: The amount of sales for the product or service.
PRODUCTS AND SERVICES Manufactured Products One Enter text: The description of a manufactured electronic product, precision instrument or medical device you make or sell.

ACORD 180 (1997/01) 5 of 14

Section Name Field Name Field and/or Section Description
PRODUCTS AND Enter amount: The amount of sale for the manufactured electronic product, precision
SERVICES Sales Amount 1 instrument or medical device you make or sell.
PRODUCTS AND Enter text: The description of a manufactured electronic product, precision instrument or
SERVICES Manufactured Products Two medical device you make or sell.
PRODUCTS AND Enter amount: The amount of sale for the manufactured electronic product, precision
SERVICES Sales Amount 2 instrument or medical device you make or sell.
PRODUCTS AND Enter text: The description of a manufactured electronic product, precision instrument or
SERVICES Manufactured Products Three medical device you make or sell.
PRODUCTS AND Enter amount: The amount of sale for the manufactured electronic product, precision
SERVICES Sales Amount 3 instrument or medical device you make or sell.
PRODUCTS AND Enter text: The description of a manufactured electronic product, precision instrument or
SERVICES Manufactured Products Four medical device you make or sell.
PRODUCTS AND Enter amount: The amount of sale for the manufactured electronic product, precision
SERVICES Sales Amount 4 instrument or medical device you make or sell.
PRODUCTS AND Enter text: The description of a manufactured electronic product, precision instrument or
SERVICES Manufactured Products Five medical device you make or sell.
PRODUCTS AND Enter amount: The amount of sale for the manufactured electronic product, precision
SERVICES Sales Amount 5 instrument or medical device you make or sell.
PRODUCTS AND Show the dollar amount of retail
SERVICES sales. Enter amount: The amount of retail sales.
PRODUCTS AND Show the dollar amount of
SERVICES wholesale sales. Enter amount: The amount of wholesale sales.
PRODUCTS AND
SERVICES Other Income One Enter text: The description of the business activity.
PRODUCTS AND
SERVICES Sales Amount 1 Enter amount: The amount of sales from the business activity.
PRODUCTS AND
SERVICES Other Income Two Enter text: The description of the business activity.
PRODUCTS AND
SERVICES Sales Amount 2 Enter amount: The amount of sales from the business activity.
PRODUCTS AND
SERVICES Other Income Three Enter text: The description of the business activity.
PRODUCTS AND
SERVICES Sales Amount 3 Enter amount: The amount of sales from the business activity.
PRODUCTS AND
SERVICES Other Income Four Enter text: The description of the business activity.

ACORD 180 (1997/01) 6 of 14

Section Name Field Name Field and/or Section Description
PRODUCTS AND
SERVICES Sales Amount 4 Enter amount: The amount of sales from the business activity.
PRODUCTS AND
SERVICES Other Income Five Enter text: The description of the business activity.
PRODUCTS AND
SERVICES Sales Amount 5 Enter amount: The amount of sales from the business activity.
PRODUCTS AND
SERVICES Other Income Six Enter text: The description of the business activity.
PRODUCTS AND
SERVICES Sales Amount 6 Enter amount: The amount of sales from the business activity.
PRODUCTS AND Check the box (if applicable): Indicates the acceptable downtime for your product or
SERVICES No Downtime Acceptable service according to your average customer's needs is no downtime.
PRODUCTS AND Downtime of less than 1 day is Check the box (if applicable): Indicates the acceptable downtime for your product or
SERVICES acceptable service according to your average customer's needs is downtime of less than 1 day.
PRODUCTS AND Downtime of less than 2 days is Check the box (if applicable): Indicates the acceptable downtime for your product or
SERVICES acceptable service according to your average customer's needs is less than 2 days.
PRODUCTS AND More than 2 days downtime is Check the box (if applicable): Indicates the acceptable downtime for your product or
SERVICES acceptable service according to your average customer's needs is more than 2 days.
PRODUCTS AND SERVICES What is the worst thing that could happen to customers' operations if the applicant's product/service were to fail or stop working? Enter text: The description of the worst thing that could happen to your customer's operations if your product or service were to fail or stop working.
What is the average life
PRODUCTS AND expectancy of each of your
SERVICES products? Enter number: The average life expectancy of the products in months.
What is the average cost of a sale
PRODUCTS AND or contract with an individual
SERVICES customer? Enter amount: The average cost of a sale or contract with an individual customer.
PRODUCTS AND What is the value of your largest
SERVICES sale or project? Enter amount: The value of the largest sale or project.
PRODUCTS AND
SERVICES Name your 5 largest customers. Enter text: The full name of a large customer.
PRODUCTS AND
SERVICES Enter text: The full name of a large customer.

ACORD 180 (1997/01) 7 of 14

Section Name Field Name Field and/or Section Description
PRODUCTS AND
SERVICES Enter text: The full name of a large customer.
PRODUCTS AND
SERVICES Enter text: The full name of a large customer.
PRODUCTS AND
SERVICES Enter text: The full name of a large customer.
List any new products or services
PRODUCTS AND you plan to introduce in the Enter text: The description of any new products or services you plan to introduce in the
SERVICES upcoming year. upcoming year.
PRODUCT DEVELOPMENT Briefly Explain Your Product
AND QUALITY CONTROL Development Methodology Enter text: The description of your product development methodology.
What is the title of the person who
PRODUCT DEVELOPMENT has primary responsibility for your Enter text: The title of the person who has primary responsibility for your quality assurance
AND QUALITY CONTROL quality assurance program? program.
PRODUCT DEVELOPMENT Describe your quality assurance
AND QUALITY CONTROL program Enter text: The description of your quality assurance program.
List all products and quality
PRODUCT DEVELOPMENT assurance standards, such as ISO Enter text: The description of all products and quality assurance standards, such as ISO
AND QUALITY CONTROL 9000, for which you are certified. 9000, for which you are certified.
Do you conduct formal
PRODUCT DEVELOPMENT inspections of requirements, Check the box (if applicable): Indicates a "Yes" response to the question, "Do you conduct
AND QUALITY CONTROL design code, and test plans? Yes formal inspections of requirements, design code, and test plans?".
PRODUCT DEVELOPMENT AND QUALITY CONTROL Do you conduct formal inspections of requirements, design code, and test plans? No Check the box (if applicable): Indicates a "No" response to the question, "Do you conduct formal inspections of requirements, design code, and test plans?".
Do you require your customers to
PRODUCT DEVELOPMENT sign off at critical milestones of a Check the box (if applicable): Indicates a "Yes" response to the question, "Do you require
AND QUALITY CONTROL project? Yes your customers to sign off at critical milestones of a project?".

ACORD 180 (1997/01) 8 of 14

Section Name Field Name Field and/or Section Description
Do you require your customers to
PRODUCT DEVELOPMENT sign off at critical milestones of a Check the box (if applicable): Indicates a "No" response to the question, "Do you require
AND QUALITY CONTROL project? No your customers to sign off at critical milestones of a project?".
PRODUCT DEVELOPMENT What percent of your products or
AND QUALITY CONTROL services do you design yourself? Enter percentage: The percentage of products or services that you design yourself.
Are redundant systems or
PRODUCT DEVELOPMENT warnings built into your product to prevent or warn against the Check the box (if applicable): Indicates a "Yes" response to the question, "Are redundant systems or warnings built into your product to prevent or warn against the product's
AND QUALITY CONTROL product's failure? Yes failure?".
Are redundant systems or
PRODUCT DEVELOPMENT warnings built into your product to prevent or warn against the Check the box (if applicable): Indicates a "No" response to the question, "Are redundant systems or warnings built into your product to prevent or warn against the product's
AND QUALITY CONTROL product's failure? No failure?".
Please list all products that you
PRODUCT DEVELOPMENT have discontinued making, but Enter text: The description of all products that you have discontinued making, but which
AND QUALITY CONTROL which are still being used. are still in use.
PRODUCT DEVELOPMENT Do you have a formal product Check the box (if applicable): Indicates a "Yes" response to the question, "Do you have a
AND QUALITY CONTROL recall plan? Yes formal product recall plan?".
PRODUCT DEVELOPMENT Do you have a formal product Check the box (if applicable): Indicates a "No" response to the question, "Do you have a
AND QUALITY CONTROL recall plan? No formal product recall plan?".
If you have ever had to recall a
PRODUCT DEVELOPMENT product, please explain the
AND QUALITY CONTROL circumstances. Enter text: The description of the circumstances surrounding a product recall.
PRODUCT DEVELOPMENT AND QUALITY CONTROL Do you have contingency plans to service a customer who has had a critical failure of your product or service? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Do you have contingency plans to service a customer who has had a critical failure of your product or service?".
PRODUCT DEVELOPMENT AND QUALITY CONTROL Do you have contingency plans to service a customer who has had a critical failure of your product or service? No Check the box (if applicable): Indicates a "No" response to the question, "Do you have contingency plans to service a customer who has had a critical failure of your product or service?".

ACORD 180 (1997/01) 9 of 14

Section Name Field Name Field and/or Section Description
PRODUCT DEVELOPMENT Do you normally install and Check the box (if applicable): Indicates a "Yes" response to the question, "Do you
AND QUALITY CONTROL service your products? Yes normally install and service your products?".
PRODUCT DEVELOPMENT Do you normally install and Check the box (if applicable): Indicates a "No" response to the question, "Do you normally
AND QUALITY CONTROL service your products? No install and service your products?".
Do you provide service and repair
PRODUCT DEVELOPMENT of products other than your own? Check the box (if applicable): Indicates a "Yes" response to the question, "Do you provide
AND QUALITY CONTROL Yes service and repair of products other than your own?".
Do you provide service and repair
PRODUCT DEVELOPMENT of products other than your own? Check the box (if applicable): Indicates a "No" response to the question, "Do you provide
AND QUALITY CONTROL No service and repair of products other than your own?".
PRODUCT DEVELOPMENT If so, what is the % of total service Enter percentage: The percentage of total service revenue generated by service and
AND QUALITY CONTROL revenue generated by this work? repair work of products other than your own.
What % of your component parts Enter percentage: The percentage of your component parts that are supplied by outside
SUPPLIERS are supplied by outside vendors? vendors.
What % of your suppliers'
components or parts are designed
SUPPLIERS by your company, but manufactured by your supplier? Enter percentage: The percentage of your suppliers' components or parts that are designed by your company, but manufactured by your supplier.
What % of your component parts
are supplied by foreign based Enter percentage: The percentage of your component parts that are supplied by foreign
SUPPLIERS companies? based companies.
SUPPLIERS Do you ever agree to hold harmless any suppliers for claims arising out of their products? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Do you ever agree to hold harmless any suppliers for claims arising out of their products?".
SUPPLIERS Do you ever agree to hold harmless any suppliers for claims arising out of their products? No Check the box (if applicable): Indicates a "No" response to the question, "Do you ever agree to hold harmless any suppliers for claims arising out of their products?".
Enter text: An explanation of a response to a general information or underwriting question.
SUPPLIERS If yes, please explain. Normally, "Yes" responses require an explanation.

ACORD 180 (1997/01) 10 of 14

Section Name Field Name Field and/or Section Description
SUB AND INDEPENDENT What, if any, development or
CONTRACTORS product work do you contract out? Enter text: The description of any development or product work that you contract out.
Do you require anyone to whom
SUB AND INDEPENDENT you contract work, to have Check the box (if applicable): Indicates a "Yes" response to the question, "Do you require
CONTRACTORS products and E&O coverage? Yes anyone to whom you contract work to have products and E&O coverage?".
SUB AND INDEPENDENT CONTRACTORS Do you require anyone to whom you contract work, to have products and E&O coverage? No Check the box (if applicable): Indicates a "No" response to the question, "Do you require anyone to whom you contract work to have products and E&O coverage?".
If yes, are you named as an
SUB AND INDEPENDENT additional insured on their policy? Check the box (if applicable): Indicates a "Yes" response to the question, "Are you named
CONTRACTORS Yes as an additional insured on their policy?".
If yes, are you named as an
SUB AND INDEPENDENT additional insured on their policy? Check the box (if applicable): Indicates a "No" response to the question, "Are you named
CONTRACTORS No as an additional insured on their policy?".
Do you require anyone to whom
SUB AND INDEPENDENT you contract work, to provide you Check the box (if applicable): Indicates a "Yes" response to the question, "Do you require
CONTRACTORS with certificates of insurance? Yes anyone to whom you contract work to provide you with certificates of insurance?".
Do you require anyone to whom
SUB AND INDEPENDENT you contract work, to provide you Check the box (if applicable): Indicates a "No" response to the question, "Do you require
CONTRACTORS with certificates of insurance? No anyone to whom you contract work to provide you with certificates of insurance?".
State the % of your products that
are directly shipped to: Other Enter percentage: The percentage of your products that are directly shipped to other
DISTRIBUTION Manufacturers manufacturers.
Enter percentage: The percentage of your products that are directly shipped to
DISTRIBUTION Wholesalers wholesalers.
DISTRIBUTION Retailers Enter percentage: The percentage of your products that are directly shipped to retailers.
Enter percentage: The percentage of your products that are directly shipped to
DISTRIBUTION Consumers consumers.
DISTRIBUTION Others (Specify) Enter text: The description of the party that your products are being shipped to.

ACORD 180 (1997/01) 11 of 14

Section Name Field Name Field and/or Section Description
DISTRIBUTION % Others Enter percentage: The percentage of your products that are directly shipped to the party described.
DISTRIBUTION Do you ever agree to hold harmless any dealers for claims arising out of your products? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Do you ever agree to hold harmless any dealers for claims arising out of their products?".
DISTRIBUTION Do you ever agree to hold harmless any dealers for claims arising out of your products? No Check the box (if applicable): Indicates a "No" response to the question, "Do you ever agree to hold harmless any dealers for claims arising out of their products?".
DISTRIBUTION If yes, please explain Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation.
MARKETING/CONTRACTS Does your legal counsel review and approve all contracts, advertising and promotional materials, and brochures? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Does legal counsel review and approve all contracts, advertising and promotional materials, and brochures?". As used here, attach copies of standard contracts, advertising and marketing material if requested by the underwriter.
MARKETING/CONTRACTS Does your legal counsel review and approve all contracts, advertising and promotional materials, and brochures? No Check the box (if applicable): Indicates a "No" response to the question, "Does legal counsel review and approve all contracts, advertising and promotional materials, and brochures?".
MARKETING/CONTRACTS Do you require your customers to sign written agreements that outline the specifications of products and services you will provide? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Do you require your customers to sign written agreements that outline the specifications of products and services you will provide?".
MARKETING/CONTRACTS Do you require your customers to sign written agreements that outline the specifications of products and services you will provide? No Check the box (if applicable): Indicates a "No" response to the question, "Do you require your customers to sign written agreements that outline the specifications of products and services you will provide?".
MARKETING/CONTRACTS Describe the training of your sales staff in terms of teaching them the characteristics and capabilities of your products and services. Enter text: The description of the training of your sales staff in terms of teaching them the characteristics and capabilities of your products and services.

ACORD 180 (1997/01) 12 of 14

Section Name Field Name Field and/or Section Description
MARKETING/CONTRACTS Is your sales staff specifically instructed not to exaggerate the capabilities of your products or services? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Is your sales staff specifically instructed not to exaggerate the capabilities of your products or services?".
MARKETING/CONTRACTS Is your sales staff specifically instructed not to exaggerate the capabilities of your products or services? No Check the box (if applicable): Indicates a "No" response to the question, "Is your sales staff specifically instructed not to exaggerate the capabilities of your products or services?".
MARKETING/CONTRACTS Force Majeure Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Do all of your contracts include the Force Majeure clause?".
MARKETING/CONTRACTS Force Majeure No Check the box (if applicable): Indicates a "No" response to the question, "Do all of your contracts include the Force Majeure clause?".
MARKETING/CONTRACTS Disclaimer of Warranties Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Do all of your contracts include the Disclaimer of Warranties clause?".
MARKETING/CONTRACTS Disclaimer of Warranties No Check the box (if applicable): Indicates a "No" response to the question, "Do all of your contracts include the Disclaimer of Warranties clause?".
MARKETING/CONTRACTS Limitation of Liabilities Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Do all of your contracts include the Limitation of Liabilities clause?".
MARKETING/CONTRACTS Limitation of Liabilities No Check the box (if applicable): Indicates a "No" response to the question, "Do all of your contracts include the Limitation of Liabilities clause?".
MARKETING/CONTRACTS Limitation of Liabilities for Consequential Damages Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Do all of your contracts include the Limitation of liabilities for consequential damages clause?".
MARKETING/CONTRACTS Limitation of Liabilities for Consequential Damages No Check the box (if applicable): Indicates a "No" response to the question, "Do all of your contracts include the Limitation of liabilities for consequential damages clause?".
MARKETING/CONTRACTS Conditions of Product Acceptance Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Do all of your contracts include the Conditions of Product Acceptance clause?".
MARKETING/CONTRACTS Conditions of Product Acceptance No Check the box (if applicable): Indicates a "No" response to the question, "Do all of your contracts include the Conditions of Product Acceptance clause?".
GENERAL INFORMATION Are you a member of a professional organization related to your business? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Are you a member of a professional organization related to your business?".
GENERAL INFORMATION Are you a member of a professional organization related to your business? No Check the box (if applicable): Indicates a "No" response to the question, "Are you a member of a professional organization related to your business?".

ACORD 180 (1997/01) 13 of 14

Section Name Field Name Field and/or Section Description
GENERAL INFORMATION Are any of your products used in the Aircraft, Space, Medical, Robotics, Pollution or Environmental Industries? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Are any of your products used in the aircraft, space, medical, robotics, pollution or environmental industries?". As used here,
GENERAL INFORMATION Are any of your products used in the Aircraft, Space, Medical, Robotics, Pollution or Environmental Industries? No Check the box (if applicable): Indicates a "No" response to the question, "Are any of your products used in the aircraft, space, medical, robotics, pollution or environmental industries?".
PRIOR INCIDENTS Are you aware of any prior incidents or problems which may lead to a claim being made against your company? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Are you aware of any prior incidents or problems which may lead to a claim being made against your company?".
PRIOR INCIDENTS Are you aware of any prior incidents or problems which may lead to a claim being made against your company? No Check the box (if applicable): Indicates a "No" response to the question, "Are you aware of any prior incidents or problems which may lead to a claim being made against your company?".
PRIOR INCIDENTS Please describe any prior incidents. Enter text: The description of any prior incidents which may lead to a claim being made against your company.
REMARKS Remarks Enter text: The general remarks associated with the errors and omissions line of business.
ATTACHMENTS ADV/Promotion Material Check the box (if applicable): Indicates ADV / Promotional Materials are attached.
ATTACHMENTS Sales Catalogues Check the box (if applicable): Indicates a sales catalogue is attached.
ATTACHMENTS STD Sales, Service or License Agreements Check the box (if applicable): Indicates standard sales, service or license agreements are attached.
ATTACHMENTS Other One Check the box (if applicable): Indicates there are attachments to the policy other than those listed.
ATTACHMENTS Other Description One Enter text: The description of an attachment to the policy.
ATTACHMENTS Other Two Check the box (if applicable): Indicates there are attachments to the policy other than those listed.
ATTACHMENTS Other Description Two Enter text: The description of an attachment to the policy.
ATTACHMENTS Other Three Check the box (if applicable): Indicates there are attachments to the policy other than those listed.
ATTACHMENTS Other Description Three Enter text: The description of an attachment to the policy.
SIGNATURE SECTION Signature and Title of Applicant Sign here: Accommodates the signature of the applicant or named insured.
Section Name Field Name Field and/or Section Description
SIGNATURE SECTION Enter text: The title of the individual in the organization or his relationship to the organization.
SIGNATURE SECTION Date Enter date: The date the form was signed by the named insured.
Edition Date The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM).

ACORD 180 (1997/01) 14 of 14