D&O Pricing Indication FORM

Please complete the form below to obtain a non-binding pricing indication for specialty insurance coverage. Ridge Canada offers specialty insurance through commercial insurance brokerages - all indications will be provided via the insurance broker contact entered below:

Please complete the form below

Note that the only required information are insurance broker details, business name and operations, annual revenue, approximate total asset value, # of employees and claim history.

Brokerage Information

Current Commercial Insurance Brokerage Name

Current Insurance Broker's Name

Current Insurance Broker's Email Address

Insured's General Information

Business Name

Business Type / Operations

Website

Approximate Total Asset Value

This should represent the approximate amount shown on the balance sheet.

Number of Employees

Total full-time and part-time employees

Approximate Annual Gross Revenue

Prior Incidents + Claims

Have their been any claims or circumstances that may lead to a claim against the firm or any individual of the firm involving the type of insurance being requested?

Yes

I don't know

Other Insurance

Are you looking for Cyber insurance coverage?

Yes

Are you looking for Technology Errors and Omissions insurance coverage?

Yes