Section 1: Company details Please provide the following details:Insured company Street No. Box Postal code City Year of establishment Website Please briefly describe below the nature of your business activities: If you have a brochure or company literature, please attach to this form Total turnover US percentage of turnover Section 2: Products Please provide details of your top 3 income generating products:Product/Product lineDescriptionTurnover Please state what makes your products and services unique:Please provide details of your top 3 competitors:NameCountry of domicileTurnover Section 3: Intellectual property Which of the following intellectual property do you hold that is relevant to your core products or services? Patents Trademarks Copyright Design rights Trade secrets Section 4: Contracts Please complete if you have any contracts which govern intellectual property, for example a licence, sale or supply agreement:Do any of the contracts impose an obligation on you to enforce any intellectual property rights? Yes No Please provide a copy of the contract Do any of the contracts impose an obligation on you to indemnify or hold harmless a third party for costs or damages in the defence of any infringement proceedings arising out of the use of intellectual property? Yes No Please provide a copy of the contract Do any of the contracts impose an obligation upon a third party to indemnify you or hold you harmless for costs or damages in the defence of any infringement proceedings arising out of intellectual property? Yes No Please provide a copy of the contract Do you retain the right to control any claim where you have an obligation to indemnify or hold harmless a third party under contract? Yes No Please explain why: Section 5: Risk Management Please summarise your current risk management procedures for intellectual property, including search practices (freedom to operate), competitor monitoring and analysis, internal and external professional services, allcoation of responsibility and legal sign off: Section 6: Legal action and loss history In respect of any intellectual property, have you ever:Commenced proceedings against, or issued a warning letter to, a third party in respect of their actual or alleged infringement of your intellectual property? Yes No Commenced proceedings against, or issued a warning letter to, a third party in respect of an actual or alleged breach of a confidentiality undertaking or licence agreement? Yes No Defended an action brought by, or received a warning letter from, a third party in respect of your actual or alleged infringement of their intellectual property? Yes No Defended an action brought by, or received a warning letter from, a third party in respect of your actual or alleged breach of a licence agreement? Yes No Defended an action brought by, or received a warning letter from, a third party threatening your ownership rights in, or validity of, any of your intellectual property? Yes No Defended an application for a declaration of non-infringement of your intellectual property? Yes No Amended your products or intellectual property rights to avoid infringing a third party's intellectual property? Yes No Please provide full details of the dates, name of parties involved, strategy and costs for each of the above selected events: Section 7: Insurance requirements Please indicate the required coverage by ticking the appropriate boxes below: Patent defence Patent pursuit Loss of intellectual property rights All other intellectual property defence All other intellectual property pursuit Loss of future profits Limit of liability Deductible Territorial limit AFTER ENQUIRY, are you aware of any cause, event or circumstance, including the existence of any prior art, which may give rise to a claim being made under this policy:against you by a third party? Yes No Please provide full details of the cause, event or circumstance and the maximum amount likely to be claimed by the third party.against a third party by you? Yes No Please provide full details of the cause, event or circumstance and the maximum amount you are likely to claim from the third party. Section 8: Declarations I declare that after proper enquiry the statements and particulars given above are true and that I have not mis-stated or suppressed any material fact. I agree that this application form, together with any other material information supplied by me shall form the basis of any contract of insurance effected thereon. I undertake to inform Vanbreda Risk & Benefits of any material alteration to these facts occurring before completion of the contract.Full name Signed Position held Date (DD, MM, YYYY)Add files Sleep bestanden naar hier of Selecteer bestanden Max. file size: 20 MB.
