Address: City: State: Zip: 

2.     EFFECTIVE DATE REQUESTED: 

3.     OPERATIONS

         A.     Nature of business: 

         B.     Does the applicant have tax exempt status as defined by the I.R.S.? Yes No

         C.     Is there or has there been any dispute as to the applicant's tax exempt status? Yes No

                   (If Yes, please provide specific details) 

         D.     Does the applicant have any subsidiaries or control any other entity for which it is requesting coverage
                  under this policy? Yes No

         (If Yes, please include a description of the operations, ownership, and tax status of each such entity)

4.     EMPLOYMENT INFORMATION:

        A.  Total Number of employees?:     volunteers?: 

        B.  How many employees have been terminated in the last year?: 

        C.  Does the applicant have formal written procedures for hiring and firing employees? Yes No

5.     PAST ACTIVITIES

         Within the last three years, has the applicant, it's directors, officers and/or any other proposed insured person
         received any complaint, suit, inquiry or notice of a hearing from any state or Federal regulatory, congressional
         or legislative committee, or any other party? Yes No

         (If Yes, please provide specific details).

6.     PRIOR INSURANCE

         Please indicate previous Directors & Officers Liability coverage on the lines below.  If none, skip this
         section and move on to question 7, Prior Knowledge Warranty.

         Insurer:     Policy Period: 

         Limit:     Deductible:     Premium: 

         You will need to forward  a copy of the prior application with any prior insurer.  The company will be relying
         on the declarations & statements contained in such prior application & those declarations & statements shall
         be considered to be incorporated in & form part of the policy of the Company.

7.     PRIOR KNOWLEDGE Please answer the following only if there has been no previous D&O coverage.

         No person proposed for coverage is aware of facts or circumstances which he or she has reason to suppose
         might give  rise to a future claim that would fall within the scope of the proposed coverage, except

         (If there are no exceptions, please state "No Exceptions" on the line provided above)

         It is agreed that if such facts or circumstances exist, whether or not disclosed, any claim arising from such facts
         or circumstances  is excluded from this proposed coverage

8.     FALSE INFORMATION

         Any person who, knowingly and with intent to defraud any insurance company or other person, files an
         application for  insurance containing any false information, or conceals for the purpose of misleading,
         information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.

9.     *ADDITIONAL INFORMATION * NOTE CAREFULLY

        In order to provide a non-binding D&O insurance
     quote you must complete the following
 
 

         12 MONTH FINANCIAL REPORT FOR

         TOTAL ASSETS

         TOTAL LIABILITIES

         NET BALANCE [+/-] BASED ON ABOVE

       It is understood that any quote we provide based on the above
     information is non-binding. Binding coverage will be subject
     to our receipt, review and approval of the following:

• Copy of most recent 12-month financial statement showing assests and liabilities
• List of the current board of directors and executive officers
• Copy of by-laws, articles of incorporation (or charter) & descriptive brochures

 

 
 



Our non-binding quote will be emailed to you along with our US mailing
address, fax number & other instructions for binding coverage.

The undersigned declares that to the best of his or her knowledge and belief that the statements set forth herein are true.  Although the signing of this application does not bind the undersigned on behalf of the applicant or it's directors, officers or other insured person to effect insurance, the undersigned agrees that this application and it's attachments shall be the basis of the contract should a policy be issued and shall be attached to and form part of this policy.  The Company is hereby authorized to make any investigation and inquiry in connection with this application that it deems necessary.

Contact Person: Address: Phone: 
E-Mail Address: 

DATE     SIGNED TITLE 

IMPORTANT INFORMATION

Your submission of this application does not obligate the Company to issue a policy.  You will be advised if your application coverage is accepted.

FALSE INFORMATION

Any person who, knowingly and with the intent to defraud any insurance company or other person, files an application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.

Notice to Florida Applicants:  Any person who, knowingly and with intent to injure, defraud or deceive any employer or employee, insurance company, or self-insured program, files a statement of claim containing any false or misleading information is guilty of a felony of the third degree.

Notice to Kentucky Applicants:  Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act which is a crime.

Notice to Minnesota and Ohio Applicants:  Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud, which is a crime.

Notice to New Jersey Applicants:  Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

Notice to New York Applicants:  Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

Notice to Oklahoma Applicants:  Any person who knowingly and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of any insurance policy containing any false, incomplete or misleading information is guilty of a felony.

Notice to Pennsylvania Applicants:  Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading information concerning any fact material thereto commits a fraudulent insurance act which is a crime and subjects such person to criminal and civil penalties.

Any person who, knowingly and with the intent to defraud any insurance company or other person, files an application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.