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Directors and Officers insurance quote for Private Companies, for profit
Application for Private Company D&O Insurance
Step
1
of
6
16%
- Directors and Officers & Private Company liability insurance;
- Employment practices liability insurance;
- Fiduciary liability insurance.
Notice:
This policy is written on a claims-made basis and covers only those claims first made during the policy period and reported in writing to the underwriter pursuant to the terms herein. This policy provides a limit of liability available to pay judgments or settlements that shall be reduced by amounts incurred as defense costs. Further note that defense costs paid shall be applied against the retention amount.
Instructions:
Whenever used in this Application the term Applicant shall mean the Named Corporation and its wholly owned/controlled Subsidiaries and their respective Directors, Officers, Trustees or Governors.
I would like to apply for
*
Directors and Officers Insurance
Employment Practices Liability Insurance
Fiduciary Liability Insurance
SECTION 1 – GENERAL INFORMATION
1. Name of Applicant:
*
2. Full Mailing Address:
*
3. Standard Industrial Classification (SIC) Code, if known:
4. Date Established:
*
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State of Incorporation:
*
SELECT
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Form of Incorporation (Inc, Ltd, LLC, etc.):
*
5. Please describe the nature of the Applicant’s operations:
*
6. Provide the name of Officer of the Applicant designated to receive any and all notices from the Underwriter or their authorized representative concerning this insurance is:
*
Section 2 - DIRECTORS & OFFICERS INFORMATION
7. Directors and Officers Liability Insurance has been continuously in force since:
*
if no present coverage, type NONE
8. Ownership Information:
a) Number of common shares outstanding:
*
a) Number of membership shares:
*
b) Number of common shareholders:
*
b) Number of active members:
*
c) Total number of shares owned directly or beneficially by Directors & Officers or Board of Managers:
*
d) Does any shareholder(s) or group of affiliated shareholders (including an employee stock ownership plan) own more than five (5)% of the voting shares directly or beneficially?
*
Yes
No
If yes, please provide details.
*
e) Are the common shares publicly traded?
*
Yes
No
If yes, please provide details.
*
f) Does the Applicant have any public debt?
*
Yes
No
If yes, please provide details.
*
g) Are there any other securities which are convertible to common stock?
*
Yes
No
If yes, please provide details
*
h) Is the Applicant owned by another entity?
*
Yes
No
If yes, indicate the name and principal address of the other entity:
*
Do you have direct and/or indirect subsidiaries?
*
Yes
No
Provide a list of all direct and indirect subsidiaries.
*
For each subsidiary provide name, type of business, percentage owned, and date created. Use "+" to add more than one subsidiary.
Name
Type of Business
Percent Owned by the Applicant:
Date Created/Acquired:
10. In the past twenty-four (24) months or in the next twelve (12) months, has the Applicant or will the Applicant be involved in any of the following:
Merger, acquisition or consolidation with another entity?
*
Yes
No
If yes, provide details
*
Sales, distribution or divestiture of any assets other than in the ordinary course of business?
*
Yes
No
If yes, provide details
*
Changes in the board of directors or senior management (other than death or retirement)?
*
Yes
No
If yes, provide details
*
Change in the Applicant’s independent auditors?
*
Yes
No
If yes, provide details
*
11. Offering of Securities Information
a) In the past thirty-six (36) months, has the Applicant completed or agreed to any private offering of debt or equity of securities, whether or not such transactions were or will be completed?
*
Yes
No
b) Within the next twelve (12) months, is the Applicant contemplating any private or public offering of debt or equity of securities?
*
Yes
No
Note: If you answered yes to 11(a) or (b), please provide details of the offering memorandum or prospectus describing the essential terms of each transaction, including the effective date, the professionals used, the amount of the offering and the current status of each such transaction.
*
12. Financial Information
a) In the past thirty-six (36) months, has the Applicant been the subject of or agreed to a bankruptcy, reorganization or arrangement with creditors under federal or state law?
*
Yes
No
b) Within the next twelve (12) months, is the Applicant contemplating any bankruptcy, reorganization or arrangement with creditors under federal or state law?
*
Yes
No
c) Is the Applicant in violation of any of its debts or loan convenants?
*
Yes
No
d) In the past thirty-six (36) months, did an Independent CPA render a “going concern” opinion?
*
Yes
No
if you yes to 12 (a), (b), (c), or (d) please attach details including the most recent financial audit, review or compilation with the auditors notes.
Drop files here or
Select files
Max. file size: 128 MB.
13. Has the Applicant, a director or officer or other person proposed for this insurance been involved in any of the following:
Anti-trust, copyright or patent infringement litigation?
*
Yes
No
If yes, please provide complete details
*
Administrative proceeding charging violation of a federal or state law or regulation?
*
Yes
No
If yes, please provide complete details
*
Representative actions, class actions or derivative suits?
*
Yes
No
If yes, please provide complete details
*
Administrative, criminal, legislative or regulatory investigation?
*
Yes
No
If yes, please provide complete details
*
Any action where a license was revoked or suspended?
*
Yes
No
If yes, please provide complete details
*
It is agreed that with respect to Question #13, if such circumstances exist, any claim arising from such circumstances is excluded from the proposed insurance.
14. Indicate the following areas in which the board has implemented formal written policies and/or procedures:
*
Select all that apply
Merger/Acquisition Procedures
Selection of New Directors
Conflict of Interest Policy
Affiliated Party Stock Transactions
Investment Policy
Related Party Transactions
Operations Procedures
Audit Policy
Personnel Policy
Compensation
Other Policies
15. Outside Directorship
Does the Applicant direct or request any individual to serve as director, officer, governor or trustee of any other entity?
*
Yes
No
a) Name of individual director, officer, governor or trustee:
*
Position held:
*
b) Name of outside entity:
*
c) Nature of entity’s business:
*
d) Percentage of ownership by Applicant:
*
Domestic or Foreign:
*
e) Does the outside entity provide indemnification to its Directors and Officers?
*
Yes
No
f) Complete the following information regarding the Directors and Officers liability insurance carried by the outside entity:
Insurer:
*
Limit of Liability $
*
Policy Period:
*
g) Has the outside entity or its Directors and Officers been involved in any Directors and Officers Liability litigation?
*
Yes
No
D&O Insurance Coverage Limit desired
*
D&O Insurance Coverage Deductible desired
*
D&O Insurance Coverage Desired effective date
*
Section 3 - EMPLOYMENT PRACTICES INFORMATION
Employment Practices Insurance Coverage Limit desired
*
Employment Practices Insurance Coverage Deductible desired
*
Employment Practices Insurance Coverage Desired effective date
*
16. Employment Practices Liability Insurance has been continuously in force since:
17. Please provide the following employee count information:
Information about current number of employees
(as of today)
Current Full Time U.S. based employees:
*
type "0" if none
Current Part Time U.S. based employees:
*
type "0" if none
Volunteers:
*
type "0" if none
Temporary:
*
type "0" if none
Leased:
*
type "0" if none
Current Non U.S. based employees:
*
Number of employees per the following states:
California
*
number of employees in California. Type "0" if none.
Florida
*
number of employees in Florida. Type "0" if none.
Jew Jersey
*
number of employees in Jew Jersey. Type "0" if none.
New York
*
number of employees in New York. Type "0" if none.
Texas
*
number of employees in Texas. Type "0" if none.
Information about prior 12 month number of employees
(as of 1 year ago)
Prior 12 month Full Time U.S. based employees:
*
type "0" if none
Prior 12 month Part Time U.S. based employees:
*
type "0" if none
Prior 12 month Non U.S. based employees:
*
type "0" if none
Information about prior 24 month number of employees
(as of 2 years ago)
Prior 24 month Full Time U.S. based employees:
*
type "0" if none
Prior 24 month Part Time U.S. based employees:
*
if none, enter "0"
Prior 24 month Non U.S. based employees:
*
type "0" if none
18. Total number of current employees with annual compensation greater than $100,000:
*
type "0" if none
19. How many employees have been terminated or demoted in the past twelve (12) months?
Voluntary:
*
if none, enter "0"
Involuntary:
*
if none, enter "0"
Laid Off:
*
if none, enter "0"
20. Is any reduction of employees or change of status anticipated or being contemplated in the next year?
*
Yes
No
If yes, number estimated:
*
21. Does the Applicant anticipate any plant, facility, branch, office, or department closing, consolidation, reorganization or layoff within the next twenty-four (24) months?
*
Yes
No
If yes, provide details.
*
22. Does the Applicant have a human resources department?
*
Yes
No
If no, describe how this function is handled.
*
23. Human Resource Policies and Procedures
Does the Applicant:
have a standard employment application for all applicants?
*
Yes
No
have an employment handbook?
*
Yes
No
document the receipt of the employee handbook by the employee?
*
Yes
No
have an "At Will" provision in the employment application?
*
Yes
No
have a written policy with respect to sexual harassment?
*
Yes
No
have a written policy with respect to discrimination?
*
Yes
No
have written annual evaluations for employees?
*
Yes
No
have a written policy on progressive discipline for employees?
*
Yes
No
have a written policy for Family Medical Leave Act?
*
Yes
No
have a written policy for Americans with Disabilities Act?
*
Yes
No
have a written human resources manual or guidelines?
*
Yes
No
use outside counsel for employment advice?
*
Yes
No
use any tests to screen applicants or employees for continued employment?
*
Yes
No
utilize any form of alternative dispute resolution (ADR) or an arbitration policy?
*
Yes
No
offer severance arrangements in return for a release from future litigation?
*
Yes
No
provide formal training for its supervisors in administering employment procedures?
*
Yes
No
provide formal diversity or cultural sensitivity training for all of its employees?
*
Yes
No
Please provide an explanation for all no answers related to Human Resource Policies and Procedures above
*
24. Third Party Policies and Procedures
Does the Applicant:
a) have policies or procedures outlining employee conduct when dealing with customers, clients, vendors, the general public or other third parties, including non-discrimination and non harassment statements?
*
Yes
No
b) have policies or procedures for responding to complaints of harassment, discrimination, or civil rights violations from its customers, clients, vendors, the general public or other third parties?
*
Yes
No
c) have employees who work at customer locations or perform a majority of their functions off-site?
*
Yes
No
If yes, Number of employees:
*
Number of locations:
*
Describe the services performed / provided:
*
25. Has the Applicant, a director or officer or other person proposed for this insurance been involved in any of the following:
Any discriminatory practice violation or litigation?
*
Yes
No
If yes, provide complete details
*
Any disciplinary action by any regulatory agency or association, including the Equal Employment Opportunity Commission
*
Yes
No
If yes, provide complete details
*
Section 4 - FIDUCIARY LIABILITY COVERAGE
Fiduciary Liability Insurance coverage limit desired
*
for example $1,000,000 or $1M
Fiduciary Liability Insurance coverage deductible desired
*
for example $1,000 or $10K
Fiduciary Liability Insurance desired effective date
*
26. Fiduciary Liability Insurance has been continuously in force since:
If no continuous coverage, type "None"
SECTION 5 - GENERAL SUMMARY
41. Please provide details on the following insurance coverage currently in place:
Directors and Officers
Insurance Company
Limit of Liability
Deductible
Policy Effective Date
Premium
Employment Practices Liability Insurance
Insurance Company
Limit of Liability
Deductible
Policy Effective Date
Premium
Fiduciary Liability Insurance
Insurance Company
Limit of Liability
Deductible
Policy Effective Date
Premium
General Liability Insurance
Insurance Company
Limit of Liability
Deductible
Policy Effective Date
Premium
Professional Liability Insurance
Insurance Company
Limit of Liability
Deductible
Policy Effective Date
Premium
a) With respect to the above coverage, has any Underwriter refused, canceled or non-renewed coverage?
*
(Not Applicable in Missouri)
Yes
No
b) With respect to the above coverage, has any Underwriter indicated any intent not to offer renewal terms to the Applicant?
*
(Not Applicable in Missouri)
Yes
No
c) With respect to the above coverage, has the Applicant given notice of any claim, circumstance or potential claim to any Underwriter?
*
Yes
No
42. Has the Applicant given written notice under the provisions of any prior policies providing similar insurance or claims, or of specific facts or circumstances which might give rise to a claim being made against any person or entity applying for this insurance?
*
Yes
No
43. No person applying for this coverage is aware of any facts or circumstances which he or she has reason to presume might give rise to a future claim that would fall within the scope of any of the proposed coverages for which the Applicant has applied, except:
*
None
as noted below:
Provide additional information
Without prejudice to any other rights and remedies of the Underwriter, any claim arising from any claims, facts, circumstances or situations whether or not disclosed in #41, #42, and #43 above is excluded from the proposed insurance.
Material Change
If there is any material change to the answers of this Application's questions prior to the policy inception date, the Applicant must notify the Underwriter in writing. Any outstanding quotation may be modified or withdrawn.
FRAUD NOTICE STATEMENTS
NOTICE TO 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 MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES."
Signature
The Undersigned represents that to the best of his/her knowledge and belief the statements set forth herein are true. The Undersigned further declares that any occurrence or event that takes place prior to the effective date of the insurance for which application is being made which may render inaccurate, untrue, or incomplete any statement made, will immediately be reported in writing to the Underwriter. The Underwriter may withdraw or modify any outstanding quotations and/or authorization or agreement to bind the insurance. The Underwriter is hereby authorized to make any investigation and inquiry in connection with the information, statements and disclosures provided in this Application. The signing of this Application does not bind the Undersigned to purchase the insurance, nor does the review of this Application bind the insurance company to issue a policy. It is agreed that this Application shall be the basis of the contract should a policy be issued. This Application will be attached and become a part of the policy.
Name
*
Title
*
(Must be signed by the President, Chairman or CEO)
AS PART OF THIS APPLICATION, PLEASE SUBMIT THE FOLLOWING DOCUMENTS:
a) Applicant’s latest fiscal year end financial statement (CPA prepared) and latest interim financial statement
b) List of the Applicant's current Directors & Officers
c) Copies of the most recently filed Forms 5500 (and attachments) for all ERISA plans for which coverage requested (If Fiduciary Liability coverage is being requested)
d) Copies of the latest versions of the Applicant’s employee handbook and employment applications
e) Copy of the Applicant’s current Directors & Officers/ EPLI Policy (optional)
THE INFORMATION CONTAINED IN AND SUBMITTED WITH THIS APPLICATION IS ON FILE WITH THE UNDERWRITER AND ALONG WITH THE APPLICATION IS CONSIDERED PHYSICALLY ATTACHED TO AND PART OF THE POLICY, SHOULD ONE BE ISSUED. THE UNDERWRITER WILL HAVE RELIED UPON THIS APPLICATION AND ATTACHMENTS IN ISSUING ANY POLICY.
Drop files here or
Select files
Max. file size: 128 MB.