Directors & Officers Insurance

Directors & Officers Insurance
GENERAL INFORMATION
Applicant Name

First NameLast Name
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State of Incorporation
Primary Nature of Business
Is the total combined employee count for the Applicant and its Subsidiaries greater than 250?

YesNo
Does the Applicant currently have similar insurance?

YesNo
Expiration date of current policy
Current Carrier

	Limits	Retro Active Date	# of Full Time Empl	# of Part Time Empl
Directors and Officers

1. There has not been nor is there now pending any claim(s) against the Applicant, its subsidiaries, or any Director, Officer or Employee of the Applicant or its Subsidiaries,arising out of: (1) any Director, Officer, Employee or entity liability matter; or (2) any matterclaimed against any person proposed for insurance in his or her capacity as a Director,Officer or Employee. (If Yes, Please attach complete details)

YesNo
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2. Does the Applicant, its Subsidiaries, or any Director, Officer or Employee of the Applicant and its Subsidiaries know of any act, error or omission, which could giverise to a Claim under the proposed policy? (If Yes, Please attach complete details)

YesNo
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3. It is agreed that with respect to Questions 1 and 2 above, if such knowledge, information or involvement exists, any claim or action arising therefrom is excluded from the proposed coverage.9. Has any insurance carrier refused, canceled or non-renewed any similar insurance?

YesNo

FINANCIAL INFORMATION
Based on Financial Statements Dated (Year/Month)
Total Assets
Total Liabilities
Is the Applicant currently operating with a positive retained earning?

YesNo
Has any auditor issued a "going concern" opinion for the Applicants or any of its Subsidiaries financial statements?

YesNo
Revenues (Most recent year)
Net Amount
Years of Operation

Less than 1 year1-3 years3-5 yearsOver 5 years

Amount of aggregate limit requested
Self-insured retention / deductible?
Provide E-Signature

Clear
1. Copy of the indemnification provisions of the charter and the by-laws.
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2. Copy of Employee Handbook and Human Resources Manual.
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3. Latest Financials with Treasurers Warranty Letter if not audited.
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4. Mainform from current carrier (if applicable).
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5. List of all direct and indirect Subsidiaries, include as to each the nature of business operation, percentage of ownership and whether such Subsidiaries are domestic or foreign.
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6. List of all Directors and Officers of the Applicant and its Subsidiaries and as to each provide any affiliations with other corporations.
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Should be Empty: