Insurance Crime & D&O Policy Form

INSURANCE CRIME & D&O POLICY FORM

Insured Information

Policy Details

Limits of Insurance

Crime Aggregate Limit:

Crime Per Loss Limit:

D&O Side A Limit (Non-Indemnifiable Directors & Officers):

D&O Side B Limit (Company Reimbursement):

D&O Side C Limit (Entity Securities Liability):

Coverage Selections

Crime Coverages (select all that apply) Employee Dishonesty — Limit:
Forgery or Alteration — Limit:
Money & Securities On-Premises — Limit:
In Transit — Limit:
Funds Transfer Fraud — Limit:
Computer Fraud — Limit:

Directors & Officers Coverages (select all that apply) Side A — Limit:
Side B — Limit:
Side C — Limit:
Employment Practices Liability (EPL) — Limit:

Exclusions (Selected)

The insurance afforded by this policy does not apply to loss, claim, damages, defense costs or other amounts arising out of, based upon or attributable to the following unless expressly added by endorsement: intentional criminal acts or fraudulent acts by an Insured; bodily injury, sickness, disease, or death; loss of or damage to tangible property (except as specifically covered in crime insuring agreements); statutory fines and penalties except where insurable; war or nuclear hazard; and any claim for which indemnity has been paid under any prior policy, except as stated in the Prior Acts/Continuity provision.

By checking the box below the Insured acknowledges receipt and review of the primary exclusions and understands they limit coverage absent specific endorsement.

Conditions, Notices & Cooperation

Notice of Claim or Circumstance: The Insured shall give written notice to the insurer as soon as practicable upon discovery of any circumstance that could reasonably be expected to give rise to a claim. Such notice shall include full particulars as are then known, and shall not be construed to extend coverage absent timely and adequate notice.

Cooperation and Proof: The Insured will cooperate with the insurer in the investigation, settlement and defense of any claim, and will provide proof and documentation of loss. Failure to cooperate that materially prejudices the insurer's rights may result in denial of coverage to the extent of the prejudice.

Subrogation: In the event of any payment under this policy, the insurer shall be subrogated to all the Insured's rights of recovery against any person or organization. The Insured shall execute all papers and do whatever else is necessary to secure such rights.

Allocation: For claims involving both covered and uncovered loss, defense costs and other amounts, allocation between covered and uncovered matters will be made in accordance with recognized industry practices and any applicable court decisions, and will be subject to audit by the insurer.

Prior Losses / Claims History

Endorsements / Schedule of Attachments

Beneficiary / Payee Designation (Recovery Proceeds)

Beneficiary 1 Name:
Relationship:
Percentage of Proceeds:

Beneficiary 2 Name:
Relationship:
Percentage of Proceeds:

Declarations, Representations and Certification

The undersigned certifies that the statements contained in this form and any attachments are true, complete and accurate to the best of the undersigned's knowledge. The undersigned understands that this policy, endorsements and coverage are issued in reliance upon the truthfulness of these statements and that material misrepresentation, omission or concealment may void coverage for the matters to which such misrepresentation, omission or concealment relates.

Fraud Warning: Any person who, with intent to defraud or knowing that they are facilitating a fraud against the insurer, submits an application, claim or other document containing a false, incomplete or misleading statement may be subject to civil or criminal penalties under applicable law. The Insured hereby authorizes the insurer to obtain and exchange underwriting and claim information about the Insured to the extent permitted by law.

Signature and Certification

By signing below the Applicant/Insured certifies that they are authorized to execute this Policy Form on behalf of the Named Insured and that the information contained herein is a true and complete representation of the facts as of the date of signature.

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