Intellectual Property Infringement Insurance Request Form
Applicant Information
Company Name
Contact Person
Email Address
Phone Number
Company Details
Business Address
Type of Business
Year Established
Number of Employees
Intellectual Property Details
Type(s) of Intellectual Property (select all that apply)
Patent
Trademark
Copyright
Design
Other
Brief Description of Intellectual Property
Insurance Coverage
Requested Coverage Amount
Coverage Start Date
Coverage End Date
Claims & History
Have you previously filed any intellectual property infringement insurance claims?
Yes
No
If yes, please provide details
Additional Information
Any additional notes or relevant information