ACORD 180 (2014/12) - ERRORS AND OMISSIONS SECTION
ACORD 180 (2014/12) - ERRORS AND OMISSIONS SECTION
ACORD 180, Errors and Omissions Section, Electronic Data Processors, Electronic Products Manufacturers, Computer Services & Products, is
used to apply for electronic data processors, electronic products manufacturers, and computer services and 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 ACORD 125, Commercial Insurance Application, Applicant Information Section.
Form Page 1
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
IDENTIFICATION SECTION
Date
Enter date: The date on which the form is completed. (MM/DD/YYYY)
IDENTIFICATION SECTION
Agency
Enter text: The full name of the producer / agency.
IDENTIFICATION SECTION
Policy Number
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being
referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for
self-insurance, the self-insured license or contract number.
IDENTIFICATION SECTION
Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the policy
commence. (MM/DD/YYYY) As used here, this is the proposed effective date.
IDENTIFICATION SECTION
Carrier
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy. Use
the actual name of the company within the group to which the policy has been issued. This is
not the insurer's group name or trade name.
IDENTIFICATION SECTION
NAIC Code
Enter code: The identification code assigned to the insurer by the NAIC.
IDENTIFICATION SECTION
Applicant / First Named
Insured
Enter text: The named insured(s) as it / they will appear on the policy declarations page.
MERGERS / ACQUISITIONS
/ JOINT VENTURES
List all mergers or
acquisitions
Enter text: The description of any mergers or acquisitions by your company (including
subsidiaries) in the mandated number of years.
MERGERS / ACQUISITIONS
/ JOINT VENTURES
List all mergers or
acquisitions
Enter text: The description of any mergers or acquisitions by your company (including
subsidiaries) in the mandated number of years.
MERGERS / ACQUISITIONS
/ JOINT VENTURES
List all mergers or
acquisitions
Enter text: The description of any mergers or acquisitions by your company (including
subsidiaries) in the mandated number of years.
MERGERS / ACQUISITIONS
/ JOINT VENTURES
List all mergers or
acquisitions
Enter text: The description of any mergers or acquisitions by your company (including
subsidiaries) in the mandated number of years.
MERGERS / ACQUISITIONS
/ JOINT VENTURES
List all mergers or
acquisitions
Enter text: The description of any mergers or acquisitions by your company (including
subsidiaries) in the mandated number of years.
ACORD 180 (2014/12) rev. 04-29-2014
Page 1 of 15
MERGERS / ACQUISITIONS
/ JOINT VENTURES
List all mergers or
acquisitions
Enter text: The description of any mergers or acquisitions by your company (including
subsidiaries) in the mandated number of years.
MERGERS / ACQUISITIONS
/ JOINT VENTURES
List all joint ventures
Enter text: The description of all joint ventures in which your company is a partner.
MERGERS / ACQUISITIONS
/ JOINT VENTURES
List all joint ventures
Enter text: The description of all joint ventures in which your company is a partner.
MERGERS / ACQUISITIONS
/ JOINT VENTURES
List all joint ventures
Enter text: The description of all joint ventures in which your company is a partner.
MERGERS / ACQUISITIONS
/ JOINT VENTURES
List all joint ventures
Enter text: The description of all joint ventures in which your company is a partner.
MERGERS / ACQUISITIONS
/ JOINT VENTURES
List all joint ventures
Enter text: The description of all joint ventures in which your company is a partner.
MERGERS / ACQUISITIONS
/ JOINT VENTURES
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.
POLICY / COVERAGE
INFORMATION
Transaction Type -
Proposed Retroactive Date
Enter date: The retroactive date you are requesting for the policy being applied for. This is the
proposed earliest date for which an occurrence could trigger coverage under a Claims Made
policy.
POLICY / COVERAGE
INFORMATION
Transaction Type -
Deductible
Enter deductible: The deductible amount for the coverage.
POLICY / COVERAGE
INFORMATION
Transaction Type - Expiring
Pol #
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being
referenced exactly as it appears on the policy, including prefix and suffix symbols. If 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 claim.
POLICY / COVERAGE
INFORMATION
Limits of Liability - Each
Occurrence
Enter limit: The limit amount for each occurrence.
POLICY / COVERAGE
INFORMATION
Limits of Liability -
Aggregate
Enter limit: The aggregate limit amount.
POLICY / COVERAGE
INFORMATION
Limits of Liability - Current
Retroactive Date
Enter date: The retroactive date if the policy was issued on a Claims Made basis and there was
a retroactive date.
ACORD 180 (2014/12) rev. 04-29-2014
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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 on which the fiscal year begins. (MM/DD/YYYY)
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. (AUD)
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 estimated domestic sales amount for the current fiscal year.
PRODUCTS AND SERVICES
Current Fiscal Year Foreign
Enter amount: The estimated foreign sales amount for the current fiscal year. (AUD)
PRODUCTS AND SERVICES
Current Fiscal Year Total
Enter amount: The estimated total sales amount for the current fiscal year.
PRODUCTS AND SERVICES
Next Fiscal Year Domestic
Enter amount: The estimated domestic sales amount for the next fiscal year.
PRODUCTS AND SERVICES
Next Fiscal Year Foreign
Enter amount: The estimated foreign sales amount for the next fiscal year. (AUD)
PRODUCTS AND SERVICES
Next Fiscal Year Total
Enter amount: The estimated 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 -One
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.
PRODUCTS AND SERVICES
Sales Amount -Two
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- Three
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 - Four
Enter amount: The amount of sales for the product or service.
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PRODUCTS AND SERVICES
Product Line - Five
Enter text: The description of the product line or service provided.
PRODUCTS AND SERVICES
Sales Amount - Five
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 - Six
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 - Seven
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 - Eight
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 - Nine
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.
PRODUCTS AND SERVICES
Sales Amount - One
Enter amount: The amount of sale for the manufactured electronic product, precision instrument
or medical device you make or sell.
PRODUCTS AND SERVICES
Manufactured Products -
Two
Enter text: The description of a manufactured electronic product, precision instrument or
medical device you make or sell.
PRODUCTS AND SERVICES
Sales Amount - Two
Enter amount: The amount of sale for the manufactured electronic product, precision instrument
or medical device you make or sell.
PRODUCTS AND SERVICES
Manufactured Products -
Three
Enter text: The description of a manufactured electronic product, precision instrument or
medical device you make or sell.
PRODUCTS AND SERVICES
Sales Amount - Three
Enter amount: The amount of sale for the manufactured electronic product, precision instrument
or medical device you make or sell.
PRODUCTS AND SERVICES
Manufactured Products -
Four
Enter text: The description of a manufactured electronic product, precision instrument or
medical device you make or sell.
PRODUCTS AND SERVICES
Sales Amount - Four
Enter amount: The amount of sale for the manufactured electronic product, precision instrument
or medical device you make or sell.
PRODUCTS AND SERVICES
Manufactured Products -
Five
Enter text: The description of a manufactured electronic product, precision instrument or
medical device you make or sell.
PRODUCTS AND SERVICES
Sales Amount - Five
Enter amount: The amount of sale for the manufactured electronic product, precision instrument
or medical device you make or sell.
PRODUCTS AND SERVICES
Retail Sales
Enter amount: The amount of retail sales.
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PRODUCTS AND 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 - One
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 - Two
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 - Three
Enter amount: The amount of sales from the business activity.
PRODUCTS AND SERVICES
Other Income - Four
Enter text: The description of the business activity.
PRODUCTS AND SERVICES
Sales Amount - Four
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 - Five
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 - Six
Enter amount: The amount of sales from the business activity.
Form Page 2
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
PRODUCTS AND SERVICES
No Downtime Acceptable
Check the box (if applicable): Indicates no downtime is acceptable for your product or service
according to your average customer's needs.
PRODUCTS AND SERVICES
Downtime of less than 1 day
is acceptable
Check the box (if applicable): Indicates the acceptable downtime for your product or service
according to your average customer's needs is less than 1 day.
PRODUCTS AND SERVICES
Downtime of less than 2
days is acceptable
Check the box (if applicable): Indicates the acceptable downtime for your product or service
according to your average customer's needs is less than 2 days.
PRODUCTS AND SERVICES
More than 2 days downtime
is acceptable
Check the box (if applicable): Indicates the acceptable downtime for your product or 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 your product /
service were to fail or stop
working?
Enter text: The description of the worst thing that could happen to your customers' operations if
your product or service were to fail or stop working.
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PRODUCTS AND SERVICES
What is the average life
expectancy of each of your
products?
Enter number: The average life expectancy of the products in months.
PRODUCTS AND SERVICES
What is the average cost of
a sale or contract with an
individual customer?
Enter amount: The average cost of a sale or contract with an individual customer.
PRODUCTS AND SERVICES
What is the value of your
largest sale or project?
Enter amount: The value of the largest sale or project.
PRODUCTS AND SERVICES
Name your five (5) largest
customers.
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.
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
List any new products or
services you plan to
introduce in the upcoming
year.
Enter text: The description of any new products or services you plan to introduce in the
upcoming year.
PRODUCTS AND SERVICES
Enter text: The description of any new products or services you plan to introduce in the
upcoming year.
PRODUCTS AND SERVICES
Enter text: The description of any new products or services you plan to introduce in the
upcoming year.
PRODUCT DEVELOPMENT
AND QUALITY CONTROL
Briefly Explain Your Product
Development Methodology
Enter text: The description of your product development methodology.
PRODUCT DEVELOPMENT
AND QUALITY CONTROL
What is the title of the
person who has primary
responsibility for your
quality assurance program?
Enter text: The title of the person who has primary responsibility for your quality assurance
program.
PRODUCT DEVELOPMENT
AND QUALITY CONTROL
Describe your quality
assurance program
Enter text: The description of your quality assurance program.
PRODUCT DEVELOPMENT
AND QUALITY CONTROL
List all products and quality
assurance standards, such
as ISO 9000, for which you
are certified.
Enter text: The description of all products and quality assurance standards, such as ISO 9000,
for which you are certified.
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PRODUCT DEVELOPMENT
AND QUALITY CONTROL
List all products and quality
assurance standards, such
as ISO 9000, for which you
are certified.
Enter text: The description of all products and quality assurance standards, such as ISO 9000,
for which you are certified.
PRODUCT DEVELOPMENT
AND QUALITY CONTROL
List all products and quality
assurance standards, such
as ISO 9000, for which you
are certified.
Enter text: The description of all products and quality assurance standards, such as ISO 9000,
for which you are certified.
PRODUCT DEVELOPMENT
AND QUALITY CONTROL
List all products and quality
assurance standards, such
as ISO 9000, for which you
are certified.
Enter text: The description of all products and quality assurance standards, such as ISO 9000,
for which you are certified.
PRODUCT DEVELOPMENT
AND QUALITY CONTROL
List all products and quality
assurance standards, such
as ISO 9000, for which you
are certified.
Enter text: The description of all products and quality assurance standards, such as ISO 9000,
for which you are certified.
PRODUCT DEVELOPMENT
AND QUALITY CONTROL
List all products and quality
assurance standards, such
as ISO 9000, for which you
are certified.
Enter text: The description of all products and quality assurance standards, such as ISO 9000,
for which you are certified.
PRODUCT DEVELOPMENT
AND QUALITY CONTROL
Do you conduct formal
inspections of
requirements, design code,
and test plans? Yes
Check the box (if applicable): Indicates a Yes response to the question, Do you conduct
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?.
PRODUCT DEVELOPMENT
AND QUALITY CONTROL
Do you require your
customers to sign off at
critical milestones of a
project? Yes
Check the box (if applicable): Indicates a Yes response to the question, Do you require your
customers to sign off at critical milestones of a project?.
PRODUCT DEVELOPMENT
AND QUALITY CONTROL
Do you require your
customers to sign off at
critical milestones of a
project? No
Check the box (if applicable): Indicates a No response to the question, Do you require your
customers to sign off at critical milestones of a project?.
ACORD 180 (2014/12) rev. 04-29-2014
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PRODUCT DEVELOPMENT
AND QUALITY CONTROL
What percent of your
products or services do you
design yourself?
Enter percentage: The percentage of products or services that you design yourself.
PRODUCT DEVELOPMENT
AND QUALITY CONTROL
Are redundant systems or
warnings built into your
product to prevent or warn
against the product's
failure? Yes
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 failure?.
PRODUCT DEVELOPMENT
AND QUALITY CONTROL
Are redundant systems or
warnings built into your
product to prevent or warn
against the product's
failure? No
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 failure?.
PRODUCT DEVELOPMENT
AND QUALITY CONTROL
Please list all products that
you have discontinued
making, but which are still
being used.
Enter text: The description of all products that you have discontinued making, but which are still
in use.
PRODUCT DEVELOPMENT
AND QUALITY CONTROL
Please list all products that
you have discontinued
making, but which are still
being used.
Enter text: The description of all products that you have discontinued making, but which are still
in use.
PRODUCT DEVELOPMENT
AND QUALITY CONTROL
Please list all products that
you have discontinued
making, but which are still
being used.
Enter text: The description of all products that you have discontinued making, but which are still
in use.
PRODUCT DEVELOPMENT
AND QUALITY CONTROL
Please list all products that
you have discontinued
making, but which are still
being used.
Enter text: The description of all products that you have discontinued making, but which are still
in use.
PRODUCT DEVELOPMENT
AND QUALITY CONTROL
Please list all products that
you have discontinued
making, but which are still
being used.
Enter text: The description of all products that you have discontinued making, but which are still
in use.
PRODUCT DEVELOPMENT
AND QUALITY CONTROL
Please list all products that
you have discontinued
making, but which are still
being used.
Enter text: The description of all products that you have discontinued making, but which are still
in use.
ACORD 180 (2014/12) rev. 04-29-2014
Page 8 of 15
PRODUCT DEVELOPMENT
AND QUALITY CONTROL
Do you have a formal
product recall plan? Yes
Check the box (if applicable): Indicates a Yes response to the question, Do you have a formal
product recall plan?.
PRODUCT DEVELOPMENT
AND QUALITY CONTROL
Do you have a formal
product recall plan? No
Check the box (if applicable): Indicates a No response to the question, Do you have a formal
product recall plan?.
PRODUCT DEVELOPMENT
AND QUALITY CONTROL
If you have ever had to
recall a product, please
explain the 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?.
PRODUCT DEVELOPMENT
AND QUALITY CONTROL
Do you normally install and
service your products? Yes
Check the box (if applicable): Indicates a Yes response to the question, Do you normally
install and service your products?.
PRODUCT DEVELOPMENT
AND QUALITY CONTROL
Do you normally install and
service your products? No
Check the box (if applicable): Indicates a No response to the question, Do you normally install
and service your products?.
PRODUCT DEVELOPMENT
AND QUALITY CONTROL
Do you provide service and
repair of products other
than your own? Yes
Check the box (if applicable): Indicates a Yes response to the question, Do you provide
service and repair of products other than your own?.
PRODUCT DEVELOPMENT
AND QUALITY CONTROL
Do you provide service and
repair of products other
than your own? No
Check the box (if applicable): Indicates a No response to the question, Do you provide service
and repair of products other than your own?.
PRODUCT DEVELOPMENT
AND QUALITY CONTROL
If so, what is the % of total
service revenue generated
by this work?
Enter percentage: The percentage of total service revenue generated by service and repair work
of products other than your own.
SUPPLIERS
What % of your component
parts are supplied by
outside vendors?
Enter percentage: The percentage of your component parts that are supplied by outside
vendors.
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SUPPLIERS
What % of your suppliers'
components or parts are
designed 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.
SUPPLIERS
What % of your component
parts are supplied by
foreign based companies?
Enter percentage: The percentage of your component parts that are supplied by foreign 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?.
SUPPLIERS
If yes, please explain.
Enter text: The description of any circumstances in which you agree to hold harmless any
suppliers for claims arising our of their products.
Form Page 3
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
SUB AND INDEPENDENT
CONTRACTORS
What, if any, development or
product work do you
contract out?
Enter text: The description of any development or product work that you contract out.
SUB AND INDEPENDENT
CONTRACTORS
Do you require anyone to
whom you contract work, to
have products and E&O
coverage? Yes
Check the box (if applicable): Indicates a Yes response to the question, Do you require
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?.
SUB AND INDEPENDENT
CONTRACTORS
If yes, are you named as an
additional insured on their
policy? Yes
Check the box (if applicable): Indicates a Yes response to the question, Are you named as an
additional insured on their policy?.
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SUB AND INDEPENDENT
CONTRACTORS
If yes, are you named as an
additional insured on their
policy? No
Check the box (if applicable): Indicates a No response to the question, Are you named as an
additional insured on their policy?.
SUB AND INDEPENDENT
CONTRACTORS
Do you require anyone to
whom you contract work, to
provide you with certificates
of insurance? Yes
Check the box (if applicable): Indicates a Yes response to the question, Do you require
anyone to whom you contract work to provide you with certificates of insurance?.
SUB AND INDEPENDENT
CONTRACTORS
Do you require anyone to
whom you contract work, to
provide you with certificates
of insurance? No
Check the box (if applicable): Indicates a No response to the question, Do you require anyone
to whom you contract work to provide you with certificates of insurance?.
DISTRIBUTION
State the % of your products
that are directly shipped to:
Other Manufacturers
Enter percentage: The percentage of your products that are directly shipped to other
manufacturers.
DISTRIBUTION
Wholesalers
Enter percentage: The percentage of your products that are directly shipped to wholesalers.
DISTRIBUTION
Retailers
Enter percentage: The percentage of your products that are directly shipped to retailers.
DISTRIBUTION
Consumers
Enter percentage: The percentage of your products that are directly shipped to consumers.
DISTRIBUTION
Others (Specify)
Enter text: The description of the party that your products are being shipped to.
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: The description of any circumstances in which you agree to hold harmless any
dealers for claims arising out of your products.
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.
ACORD 180 (2014/12) rev. 04-29-2014
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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.
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?.
ACORD 180 (2014/12) rev. 04-29-2014
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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?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether you are a member of a professional organization
related to your business.
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?.
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?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether any of your products are used in the aircraft, space,
medical, robotics, pollution or environmental industries.
ACORD 180 (2014/12) rev. 04-29-2014
Page 13 of 15
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.
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 application 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 application 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 application other than those
listed.
ATTACHMENTS
Other Description Three
Enter text: The description of an attachment to the policy.
REMARKS
Remarks
Enter text: The general remarks associated with the errors and omissions line of business.
Form Page 4
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
SIGNATURE
Producer's Signature
Sign here: Accommodates the signature of the authorized representative (e.g., producer, agent,
broker, etc.) of the company(ies) listed on the document. This is required in most states.
ACORD 180 (2014/12) rev. 04-29-2014
Page 14 of 15
SIGNATURE
Producer's Name (Please
Print)
Enter text: The name of the authorized representative of the producer, agency and/or broker
that signed the form.
SIGNATURE
State Producer License No
(Required in FL)
Enter identifier: The State License Number of the producer.
SIGNATURE
Applicant's Signature
Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE
National Producer Number
Enter identifier: The National Producer Number (NPN) as defined in the National Insurance
Producer Registry (NIPR). Note: The NPN is not the same as the producer state license
number.
SIGNATURE
Applicant's Title
Enter text: The title of the individual in the organization or his relationship to the organization.
SIGNATURE
Date
Enter date: The date the form was signed by the named insured. (MM/DD/YYYY)
ACORD 180 (2014/12) rev. 04-29-2014
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