D & O Insurance

Please read and check below all coverages you seek. Fully answer all questions and submit all requested information for each coverage you seek. All applicants must complete the General Information and the final section of this application. Terms appearing in bold face in this Application are defined in the Policy and have the same meaning in this Application as in the Policy. This Application, including all materials submitted herewith, shall be in confidence.

"*" indicates required fields

Step 1 of 3

33%

The Company to be Named in item 1 of the Declarations (the "Company")*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Phone

Officer designated to receive correspondence and notices from the insurer

Name*

Title

Please provide the following information regarding current insurance coverage:*

Insurance

Carrier

Limits (in MMs)

Premium

Expiration

Example of Insurances to add - D&O Liability, Crime/Fidelity, Employment Practices, Fiduclary Liability.

Directors and Officers Liability Application

Please attach copies of the following with respect to the Company and Subsidiaries:
Any notice of annual meeting to stockholders and proxy statements within the last twelve months.
Any form 13D, 10-K, 10-Q, 8-K, or S-1 filed with the Securities and Exchange Commission within the last twelve months.
Current indemnification provisions, the charter and by-laws.
Audited financial statements for the last three years.
A schedule of all Subsidiaries to be insured under this policy, and List of directors of Company, including their principal business affiliations and the number of years each one has been a director of the company.

If the applicant is requesting coverage for outside position liability with a for-profit outside entity, please attach the following:
The name and address of the outside entity.
Any litigation pending during the last three years against any of the directors and officers of the outside entity and If the outside entity is not publicly-traded, the outside entity's audited financial statements for the last three years.

Please upload copies of the requested documents.*

Max. file size: 64 MB.

Is there any shareholder or group of affiliated shareholders who own 5% or more of the Company's outstanding common equity shares, directly or beneficially? if "YES", please use the box below for full details.*

Yes

Details*

Is the Company or any Subsidiary anticipating or contemplating any registration of debt or equity securities with the securities and Exchange Commission or any merger, consolidation, acquisition, tender offer, divestment or the sale of more than 10% of its total stock outstanding?*

Yes

During the last 12 months:

Has the Company or any Subsidiary filed a registration statement with the Securities and Exchange Commission?*

Yes

Has the Company or any Subsidiary been involved in or publicly disclosed any atual, attempted or contemplated merger, consolidation, acquisition, tender offer, divestment or the sale of more than 10% of its total stock outstanding?*

Yes

Has the Company Suspended its divident payments or is it currently contemplating such a suspension? if "YES" to any of the above, Please use the box below to add full details.*

Yes

Details*

During the last 12 months, have the Company's outside auditors stated that there are any material weaknesses in the Company's system of internal controls? if "YES", please use the box below to add full details.*

Yes

Details*

Has the Company changed auditors in the past three years? if "YES", please use the box below to add full details*

Yes

Details*

Has any director or officer of the Company or any Subsidiary signed a non-complete agreement with any outside corporation or any other legal entity during hte last five years? if "YES", please use the box below to add full details*

Yes

Details*

In the last past three years, has any executive officer or members of the board of directors of the Company resigned or been forced to resign for reasons other than retirement, poor health or promotion? if "YES", please use the box below to add full details*

Yes

Details*

During the last three years, have any of the insureds been involved in:

Any anti-trust, copyright or patent litigation?*

Yes

Any civil, criminal or administrative proceedings charging a violation of federal or state securities law or regulation?*

Yes

Any other criminal proceeding?*

Yes

Any representative actions, class actions or derivative suits?*

Yes

Any other material litigation?*

Yes

Any claim or potential claim noticed under any directors' and officers' liability policy?*

Yes

If "YES", to any of the questions above, please add full details here.*

Has the current or any previous directors' and officers' liability insurer canceled or indicated an intent not to renew any directors' and officers' liability policy? if "YES", please use the box below to add full details*

Yes

Details*

Is any person proposed for coverage aware of any fact or circumstance or any atual or alleged act, error, or omission 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? if "YES", please use the box below to add full details*

Yes

Details*

It is agreed that if such fact or circumstance or actual or alleged act, error or omission exists, whether or not disclosed, any claim arising therefrom is excluded from the proposed coverage.

To Be Completed by All Applicants

None of the Insureds is responsible for or has knowledge of any WRONGFUL ACT or fact, circumstance, or situation which (s)he has reason to suppose might result in a future Claim, except as follows:

if "NONE", please check this box

It is agreed by all concerned that if any of the Insured is responsible for or has knowledge of any Wrongful Act, fact, circumstance, or situation which (S)he has reason to suppose might result in a future Claim, whether or not described above, any such Claim subsequently emanating therefrom shall be excluded from coverage under the proposed insurance.
This Application shall be maintained on file by the insurer, shall be deemed attached as if attached to the proposed Policy and shall be considered as incorporated into and constituting a part of the proposed Policy.

The persons signing this Application declare that to the best of their Knowledge the statements set fourth herein and the information in the materials submitted herewith are true and correct and that reasonable efforts have been made to obtain sufficient information from all the Insureds to facilitate the proper and accurate completion of this Application for the proposed Policy. Signing of this Application does not bind the undersigned to purchase the insurance, but it is agreed that this Application shall be the basis of the contract should a Policy be issued. The undersigned agrees that if after the date of this Application and prior to the effective date of any Policy based on this Application, any occurrence , event or other circumstance should render any of the information contained in this application inaccurate or incomplete, then the undersigned shall notify the Insurer of such occurrence, event or circumstance and shall provide the Insurer with information that would complete, update or correct such information. Any outstanding quotations may be modified or withdrawn at the sole discretion of the Insurer.

The information requested in this Application is for underwriting purposes only and does not constitute notice to the Insurer under any Policy of a Claim or potential Claim. All such notices must be submitted to the Insurer pursuant to the terms of the Policy, if and when issued.

The undersigned acknowledges that he or she is aware that defense costs reduce and may exhaust the applicable Limits of Liability. The insurer is not liable for any Loss (which includes Defense Costs) in excess of the applicable Limits of Liability.

Name*

First Last

Title*

Corporation*

Date*

MM slash DD slash YYYY

FOR NEW YORK RESIDENTS ONLY:

WARNING
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON, FILES AN APPLICATION FOR INSURANCE FOR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY MATERIAL FACT 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

This application must be signed by the Chairman of the Board or by the President

Name

First Last

Title*

Corporation

Date

MM slash DD slash YYYY

A POLICY CANNOT BE ISSUED UNLESS THE APPLICATION IS PROPERLY SIGNED AND DATED.

Phone

This field is for validation purposes and should be left unchanged.

Officer designated to receive correspondence and notices from the insurer

Directors and Officers Liability Application

To Be Completed by All Applicants

FOR NEW YORK RESIDENTS ONLY:

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Officer designated to receive correspondence and notices from the insurer

Directors and Officers Liability Application

To Be Completed by All Applicants

FOR NEW YORK RESIDENTS ONLY:

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Latest News

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