riSk aSSeSSment Questionnaire - Captive Alternatives · Losses from cyber attacks, cyber extortion,...

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riSk aSSeSSmentQuestionnairefor insurable business risks™ bundled Coverages

Risk Assessment Questionnaire (“RAQ”) for

Insurable Business Risks™ Bundled Coverages

NOTE: ALL INFORMATION YOU PROVIDE TO US WILL REMAIN STRICTLY CONFIDENTIAL.

Legal name & d/b/a’s:

Primary contact person, email, phone

Other persons to include: person, title, email, phone

Primary/home office mailing address

Website or websites:

Description of your primary business activities, geographic location of your business, primary customer

targets, and brief company history (if this is on your website, we will obtain this information from there.)

Please state company entity type and ownership information. (Note: this information is now needed for

analysis purposes due to 2015 PATH tax act amendments, section 333)

Do you have subsidiaries, or related entities, if “yes” please briefly list/describe, or provide an organization-

al chart.

Last year’s gross revenues (approx.):

Last year’s net income before taxes (approx.)

Approximate number of full time employees:

Approximate risk budget, if known:

Please provide your business’ financial statements for last two years plus current YTD, preferably in excel

spreadsheet format 2014 2015 2016 YTD

Please provide copies of two years most recent filed federal tax returns most recent prior year

Please list your initial requests and overall goals in connection with this Insurable Business Risk Assess-

ment Questionnaire; please also list your major questions if you have any “up front”;

Please deliver this completed “IBRA” and requested attachments to Captive Alternatives, LLC, attention Mark Sims. Preferable delivery is via email attachment to: [email protected].

CapAlt RAQ Page 2

© Copyright 2016 Captive Alternatives LLC

THESE SELF ASSESSMENT QUESTIONS ARE FOR IDENTIFIABLE AREAS OF INSURABLE BUSINESS RISKS.

PLEASE COMPLETE THIS INFORMATION IF THE RISK TOPIC IS RELEVANT TO YOU IN CONNECITON WITH

YOUR BUSINESS IN ANY MANNER. SOME OF THESE TOPICS OVERLAP, AND ALL ARE POTENTIALLY USEFUL.

YOU WILL HAVE THE OPPORTUNITY TO OBTAIN INSURABLE BUSINESS RISK PREMIUM QUOTATIONS FROM

WHICH YOU CAN SELECT DESIRED OR OMITTED COVERAGES AND DESIRED PER CLAIM LIMITS LEVELS

1) LOSS OF INCOME FROM LOSS OF KEY PERSONS OR KEY TALENT : This “business interruption indemnity” type

of insurable business risk covers losses of your business’ listed “Key Persons” where the losses are caused by

fortuitous events not under your direct control. This coverage can thereby provide for continuation of expected gross

and net profit margins for stated periods of time following the loss of a key person, including:

Losses of gross income attributable to the loss of listed “Key Person” or “Key Persons” for a defined time period,

Reimbursements to business overhead expenses due to the loss of the key persons for a defined time period,

Reimburses for the key person replacement costs or temporary replacement services, and/or

Reimburses for any potential legal costs from a suit related to the loss of the key person.

List the “key persons” or “key talent” associated with your business (include yourself, any owners, the main officers or

managers of your business, or key independent contractors providing essential services for your business, whose loss

would result in diminution of business income or net profits, or increase in cost of goods sold or overhead expenses:

Name Position with the Company Age Gender Annual compensation

1.

2.

3.

4.

5.

6.

(Please provide an additional list if more persons are considered “Key Persons” to your business.

Describe any programs presently in place which would be payable to your company (such as buy/sell agreements, life

insurance or disability programs etc. which would come into play in the event of the loss of any of the above key per-

sons. (If “none”, then please state “none.”)

2) LOSS OF INCOME FROM LOSS OF KEY CONTRACTS, KEY CUSTOMERS OR KEY REFERRAL SOURCES:

This “business interruption indemnity” type of insurable business risk covers losses caused by fortuitous events over

which you have no direct control in connection with the loss of a key contract, key customer or key referral source for a

defined time period. This coverage can provide continuity of expected gross and net profit margins for stated periods

of time following the loss of a key contract, key customer or key referral source, including:

Losses of gross income attributable to the loss of listed “Key Contracts, Key Customers or Key Referral Sources” for a

defined time period,

Reimburses your company for losses of the key contract’s attributable contribution to business overhead costs for a

defined period of time,

Reimburses your company for replacement costs associated with key contract replacement efforts, and/or

Reimburses for any potential legal costs from a suit related to the loss of the key contract.


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Insurable Business Risks™

Assessments By Topic

(Continuation of “2. Loss of Key Contracts/ Key Customers / Key Referral Sources” Self Assessment)

List the “key contracts” or “key sources of business income”” associated with your business (include any direct contracts

with key customers, endorsement contracts, royalty contracts, or any other contractual source of business income) whose

loss would result in diminution of business income or net profits, or increase in cost of goods sold or overhead expenses

(Please provide us with a copy of the listed “key contracts”):

Contract/Customer Name Description Years of Duration Approx. Annual Income or % of gross income

1.

2.

3.

4.

5.

6.

(If you have more than six key contracts/ key customers or key referral sources, please provide a separate list.) 3) BRAND, REPUTATION or GOODWILL REHABILITATION (can include endorsement for social media

“incoming”); This “Business Interruption Indemnity” covers losses caused by fortuitous events not under your direct con-

trol due to negative publicity which damages your business brand , business reputation, or your company’s goodwill. Note

that this coverage can include social media “incoming” communications; (separate questions about your social media

presence or programs follow coverage number four). This insurable business risk covers:

loss of income from negative publicity,

Investigative services in relation to the negative publicity,

Public relations expenses incurred to protect or to restore your brand, reputation or goodwill in response to negative

publicity, and/or

To cover other proximately related protection or rehabilitation expenses.

Please describe your general business reputation and perceived sources of potential negative publicity:

Please list any names, brands, trademarks or copyrights associated with your business, and your perceived value of these

reputational assets in relation to your business’ annual gross income.

Do you work with any public relations firms or agents? Please list and describe their authority and activities regarding the

protection or promotion of your brand.


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Assessments By Topic (continued)

4) CYBER RISK (can include endorsement for social media “outgoing”); Cyber Risk or Technology Package is a

“business interruption indemnity” coverage which covers losses caused by fortuitous events not under your direct control in

the newly emerging arena of the Information Technology world and which are not covered under traditional general liability

coverages. Cyber Risk coverage can be direct and primary, or to cover the “excess of limits” of existing cyber risk or

technology package coverages. Cyber Risk covers:

Losses or damages proximately related to the use of computers, networks, file servers, websites, or other electronic plat-

forms,

Losses from cyber attacks, cyber extortion, identity theft, hackers, theft of private personal data, financial data, credit

card or bank account data, trade secrets, customer lists, business contracts, and similar business assets,

Covers liability which may arise in connection with the improper release of private or sensitive information,

IT related actions which may be the violation of state and federal statutes and administrative laws,

Liability associated with libel, slander, copyright infringement, product disparagement or reputational damages to others

when allegations involve a business website, social media (“outgoing”) or print media,

Reimbursements of the costs associated with data breaches such as notice to customers,

Costs of replacement of damaged hardware or software, recovery or replacement of data systems, remediation, costs of

investigation, and/or

Costs of defense of regulatory or legal actions resulting from the data losses.

Do you already carry cyber risk coverage? Yes: No: If “no” we will provide a quotation for direct coverage.

If “Yes” please provide a copy of your present coverage and indicate whether you would like to receive a quotation for:

Difference in Condition or “GAP” coverage: “Excess coverage (i.e. greater limits) Or both:

Please describe your business’ IT system or systems, and safeguards which are in place regarding potential cyber attacks or

theft of sensitive data:

Please list your primary websites:

List other websites or any reserved domain names.

3A and 4A) SOCIAL MEDIA PRESENCE AND PARTICIPATION; BOTH “INCOMING” AND “OUTGOING”; Social Media

is the new way of doing business, and its use and growth are associated with risks that are unique to the social media

platform itself. “Social media endorsements” should be issued with Brand or Reputational risks for “incoming social

media” (what others are “sending in to you”) and with Cyber Risks for “social media outgoing” (what you or your authorized

agents “send out” into the social media universe.)

Do you employ in house or external social media agents or social medial public relations firms? If yes, please describe:

Is anyone performing social media metrics for your social media campaigns? If yes, please describe:

If you use the following social media outlets, please provide the full name and URL of official profile:

Social Media Platform: “Yes” Full name and URL of your business’ “official profile”:

1. Facebook 2. Twitter 3. Instagram 4. YouTube 5. Snapchat (continued on next page)


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(Continuation from prior page)

Social Media Platform: “Yes” Full name and URL of your business’ “official profile”:

6. Reddit 7. Pinterest 8. Tumblr 9. Google + 10. LinkedIn 11. Other Do you have any notable parody accounts or lookalikes? (If yes, please provide full name and URL of parody profile(s)) Social Media Platform: “Yes” Full name and URL of your business’ “parody profiles”:

1. Facebook 2. Twitter 3. Instagram 4. YouTube 5. Snapchat 6. Reddit 7. Pinterest 8. Tumblr 9. Google + 10. LinkedIn 11. Other Do you have any official branded hashtag campaigns, popular memes, etc.? (If yes, please provide platforms where said campaigns are most prominent)

5) ADMINISTRATIVE OR REGULATORY ACTIONS COVERAGES; This “business interruption indemnity” type of coverage provides reimbursement for losses caused by fortuitous events not under your direct control due to any action brought against you by any governmental agency (federal, state or local), or any enforcement actions by governmental agencies investigating or enforcing any laws or regulations which apply to your industry or to your business. This can include:

Reimbursement of losses of income to your business due to the governmental agency action,

Reimbursement of defense costs or legal expenses incurred in connection with any covered event, and/or

Reimbursement of costs of remediation for government ordered changes associated with any covered event Please list known “governmental agencies” which have jurisdiction over your business activities and which could bring agen-cy actions against your business. If you have any incidents of past administrative actions, please describe. Agency Subject matter jurisdiction Any past actions against you? 1. 2. 3. 4. 5. 6. 7.


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6) DEFENSE COSTS AND LEGAL EXPENSE REIMBURSEMENTS; This “Business Interruption Indemnity” covers the

incurrence of our culture’s new addition to the “list of certainties” of death, taxes, and attorneys fees. This coverage

provides reimbursement for your business’ losses due to fortuitous events not under your direct control which involve the

incurrence or payment of defense costs or attorneys fees. These coverages can be direct coverages (if your business has

no existing coverage which provides for defense costs or legal fees) as well as “secondary” and “excess” to other contracts

or insurance coverages which contain costs of defense and legal costs as part of the contract or insurance coverage terms.

If coverage is primary, then reimbursements may also be made for any investigative expenses, any court costs or fees

from mediation, arbitration, or similar proceedings, prejudgment interest, or post judgment interest.

Does your business have “in house” legal counsel or an “in house” legal department? Yes: No:

If “yes”, would your in house counsel or legal department handle the defense or the response to any regulatory or legal

action? Yes: No: If “no” please describe how outside counsel would be obtained.

7) LOSS OF INCOME FROM LOSS OF KEY SUPPLIERS, KEY VENDORS, OR SUPPLY CHAIN INTERRUPTION. This “business interruption indemnity” type of coverage reimbursement for losses caused by fortuitous events not under

your direct control for the loss or business disruption from a key supplier being unable to supply product or services for

more than a three month period as well as disruptions to your supply chain for longer than forty five days. Coverages are

intended to provide : a) Reimbursement of losses to your business from loss of a Key Supplier for longer than a three

month time period, (shorter time periods can be quoted), b) Reimbursement of losses to your business from a supply chain

interruption for longer than a 45 day period , and c) Reimbursement of remedial actions or other costs reasonably incurred

by your company to replace key suppliers.

Does your business have key suppliers or key vendors, or an identifiable supply chain? Yes: No:

If yes, please provide information for each “key vendor” or “Key supplier”” Name Product or service Length of relationship approx. % of your COGS: 1. 2. 3. 4. 5. Provide additional list if necessary 8) TRANSPORTATION DAMAGES This “business interruption reimbursement indemnity” type of coverage covers losses

caused by fortuitous events not under your direct control for the loss or business disruption from damages to transported

goods during the process of delivery of those goods to the intended customer.

Does your company provide transportation services of goods for delivery to intended customers? Yes: No:

If “yes” please describe the specifics of your business transportation operations:

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9) REPRESENTATIONS AND WARRANTIES COVERAGES; This “liability indemnity” type of coverage can be either direct or “excess” of existing R&W coverages. This coverage provides reimbursement for losses caused by fortuitous events not under your direct control of any breaches to your business’ contractual representations or warranties, either expressed or reasonably implied under the law of the State in which the contract is enforced. This includes:

Reimbursement of losses to your business from covered breaches of Representations and Warranties,

Reimbursement of defense costs or legal expenses in connection with any covered event, and/or

Reimbursement of investigatory costs or other costs reasonably associated with any covered event Are you or your business party to any contract which contains “Representations or Warranties”? If so, please provide this information and please send us a copy of the contract that you are listing. Contract Parties Contract Description Contract term: Nature of Reps & Warranties 1. 2. 3. 10) KIDNAP/RANSOM/EXTORTION or “FAMILY PROTECTION COVERAGE” This “Reimbursement Indemnity”

coverage reimburses your business for fortuitous events not under your direct control involving the kidnapping, ransom,

detention, hijack, stalking, or extortion of “Named Protected Persons” (which can be extended to their family members.)

This KRE coverage can also include reimbursements for damages to property lost in connection with a covered event and

the cost of security or investigative services in connection with a covered event. This coverage can either be direct or

“secondary” or “excess” to existing KRE coverage.) A material condition of the issuance of this coverage is that you do not

communicate to others outside of your business that your business is carrying this KRE coverage.

For intended covered persons, (including yourself) please list: (Note: family members can be included on this list.)

Name Position with Business Gender Age Annual compensation (if any)

1.

2.

3.

4.

5.

(If additional persons are included, please provide a continuation list.)

11) LOSS OF INCOME FROM LABOR STOPPAGE, EXTENDED LABOR SHORTAGE OR UNAVAILABILITY. This “business interruption indemnity” type of coverage reimbursement for losses caused by fortuitous events not under

your direct control for the loss significant portions of your labor force or extended labor shortages or unavailability of trained

or specialized workers.

Does your business have a labor force which is key to the successful operations of your business? Yes: No:

If yes, please describe:

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Question 12: HIGH DEDUCTIBLE REIMBURSEMENT COVERAGES FOR YOUR EXISTING COMMERCIAL PLANS: Captive Insurance Companies are an excellent way to participate in your good claims histories, to save on present day insurance costs (which can be reduced with your taking on a “high deductible,” and offer the opportunity for your company to put risk and claims mitigation programs in place which benefit all parties over the long term. There are four high deductible programs which you can obtain High Deductible Funding coverage, and participate in this coverage with your captive insurance company participating in the reinsurance of the high deductible funding program. A) HIGH DEDUCTIBLE FUNDING FOR MEDICAL OR HEALTH PLANS: Please state your present carrier for this coverage: Est. Annual premium:

Please provide statistics for presently covered plan participants: Please state present retentions or deductibles:

Please provide a copy of your present coverage and indicate the estimated amount of stop loss or total deductible that you are willing to consider insuring via the CapAlt Protected Captive model:

B) HIGH DEDUCTIBLE FUNDING FOR PROFESSIONAL LIABILITY OR MEDICAL MALPRACTICE PLANS: Please state your present carrier for this coverage: Est. Annual premium:



C) HIGH DEDUCTIBLE FUNDING FOR WORKERS COMPENSATION PLANS: Please state your present carrier for this coverage: Est. Annual premium:



D) HIGH DEDUCTIBLE FUNDING FOR SELECTED COMMERCIAL COVERAGES: Please state your present carrier for this coverage: Est. Annual premium:



CapAlt RAQ Page 9 © Copyright 2016 Captive Alternatives LLC



THIS PAGE COVERS INSURABLE BUSINESS RISKS FOR FORTUITOUS EVENTS NOT UNDER YOUR DIRECT

CONTROL AND WHICH MAY BE PRIMARY (DIRECT), OR, IF YOU HAVE PRESENT COMMERCIAL COVERAGE

FROM ANOTHER CARRIER, MAY COVER “GAPS” IN PRIMARY COVERAGE, OR EXCESS (HIGHER LIMITS) TO

YOUR BUSINESS’ EXISTING INSURANCE COVERAGES, OR BOTH GAP AND EXCESS TOGETHER.

13) GENERAL LIABILITY; This coverage protects against a broad range of potential legal obligations.

Do you already have this kind of coverage? Yes: No: If “no” we will provide a quotation for direct coverage.



14) PROFESSIONAL LIABLITY/MALPRACTICE LIABILITY; This “Liability Indemnity” coverage provides a broad range

of potential legal obligations due breaches of professional duty required by law.


Do the hospitals where you practice require coverage from a “California admitted carrier?” Yes: No:

Number of physicians and professional staff included in your coverage: Present annual premium:

Please provide a copy of your present declarations page and indicate whether you would like to receive a quotation for:


15) ERRORS & OMISSIONS: This coverage protects against liability from your errors and omissions.




16) EMPLOYMENT PRACTICES LIABILITY This “Liability Indemnity” coverage provides insurance protection for your

hiring, termination, and employment practices liabilities.




17) DIRECTORS & OFFICERS LIABILITY This “Liability Indemnity” covers the officers and directors of your company.




18) FIDUCIARY LIABLITY; This “Liability Indemnity” coverage protects your actions in connection with any charitable

activities or the officers and directors of any of your related foundations or charitable entities.







INSURABLE BUSINESS RISKS (continued)

19) EMPLOYEE DISHONESTY; This covers actions of employee theft or wrongful acts.




20) COMMERCIAL PROPERTY INDEMNITY This coverage protects your commercial property.




21) PRODUCT WARRANTY INDEMNITY This provides protection from breaches of any warranties, actual or

implied, with regard to any of your products or services which carry warranties.




22) PRODUCT RECALL REIMBURSEMENT INDEMNITY This provides indemnification for costs and expenses

associated with product recalls caused by fortuitous circumstances not under your direct and intentional control.




23) CORPORATE DISABILITY INDEMNITY This coverage provides disability protection for your named employees.




24) EARTHQUAKE This coverage protects against losses due to earthquakes and ground tremors.




25) WIND This coverage protects against losses due to Wind, tornados, and severe storms.







INSURABLE BUSINESS RISKS (continued)

26) ENVIRONMENTAL LIABILITY This coverage protects against environmental claims and clean up costs.



Difference in Condition or “GAP” coverage: “Excess coverage (i.e. greater limits) Or both

27) TERRORISM (BROAD DEFINITION) This “Reimbursement Indemnity” coverage protects your company from any

damages caused by terrorist events in your geographic area or which affect your business.




28) INTELLECTUAL PROPERTY INDEMNITY This coverage protects against liabilities incurred in connection with

the unintentional infringement upon the intellectual property rights of others.




29) COMMERCIAL CRIME This reimbursement indemnity coverage protects against losses to money, securities,

or other property due to a variety of illegal actions by third parties.




30) COMMERCIAL OUTPUT This coverage protects against losses to produced materials or stock during the

production or pre-delivery of your company’s products due to fortuitous events not under your direct control.




31) GENERAL BUSINESS LIABILITY (FOREIGN) This coverage protects against losses for those portions of your

business which are outside the United States. Do you do business outside of the United States? Yes: No:

Please describe your non-U.S. business and approximate percentage of your business conducted outside the US.:







INSURABLE BUSINESS RISKS (concluded) Note: “Blank” answers means you are not interested in the coverage.

32) BUILDERS RISK INDEMNITY This coverage protects a construction business from losses of building materi-

als, fixtures, or equipment during the construction phase of the project and before project completion.

Please provide information about approx. portion of your business is “projects under construction”:




33) MANAGEMENT LIABILITY INDEMNITY This coverage protects management companies against losses from

their property or business management practices.




34) INTERNATIONAL TRAVEL MEDICAL REIMBURSEMENT INDEMNITY This coverage provides reimbursement for

medical expenses incurred when traveling abroad.




35) CROP INSURANCE This coverage protects against losses due to failure of crops to attain stated yields.

Do you already have this kind of coverage? Yes: No: If “no” we will provide a quotation for direct coverage if

you will reply to our request for a separate set of crop and acreage application data.



36) FLOOD INSURANCE This coverage protects against losses due to floods. .

Do you already have this kind of coverage? Yes: No: If “no” we will provide a quotation for direct coverage if

you will reply to our request for a separate set of property/flood plane and other related application data.



37) DO YOU HAVE ANY ADDITIONAL COVERAGE REQUESTS OR QUESTIONS YOU WOULD LIKE ANSWERED AT

THIS TIME?

THANK YOU FOR YOUR COMPLETION OF THIS CAPTIVE ALTERNATIVES RISK ASSESSMENT QUESTIONAIRRE.

PLEASE SAVE A COPY FOR YOURSELF AND PLEASE EMAIL THIS COMPLETED FORM TO: MARK SIMS, VP of

Business development: [email protected]

YOU WILL BE PROVIDED WITH A SELECTION SPREAD SHEET OF THE COVERAGES YOU HAVE ASKED US TO

PROVIDE; YOU WILL HAVE THE ABILITY TO SELECT DIFFERENT LIMITS OF COVERAGE OR COVERAGE TIME

PERIODS. ANY LICENSED INSURANCE PRODUCTS ARE PLACED BY LICENSED PRODUCERS IN YOUR STATE.



Assessments By Topic (concluded)

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riSk aSSeSSment Questionnaire - Captive Alternatives · Losses from cyber attacks, cyber extortion,...

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