Insurance D&O Applications

DIRECTORS & OFFICERS (D&O) INSURANCE APPLICATION

Applicant / Insured Information

Contact Person:     Telephone:     Email:

Organizational Details

Year Established:     Number of Employees:

Corporation   Limited Liability Partnership   Partnership   Nonprofit/Charity   Other:

Policy Requested

Requested Effective Date:     Requested Expiration Date:

Deductible / Retention:     Annual Premium (estimate):

Coverage Options and Limits

Claims-Made Form     Occurrence Form

Defense within Limits: Yes   Defense outside Limits: Yes   Insured vs Insured Exclusion Waiver Request: Yes

Operations and Securities

Yes   No

Prior Insurance, Claims & Loss History

Yes   No

Additional Questions & Representations

Has any director, officer, or the organization been the subject of any regulatory, administrative or criminal investigation or enforcement proceeding?     Yes   No

Has the entity or any officer or director filed for bankruptcy in the past 10 years?     Yes   No

Exclusions, Conditions and Attachments

The proposed insurance, if issued, will be subject to standard D&O policy exclusions including but not limited to fraud and intentional wrongdoing, bodily injury and property damage, pollution, and prior acts not disclosed unless a prior-acts date is agreed. Applicant must disclose all material facts; non-disclosure or misrepresentation may result in rescission or denial of coverage.

Most recent audited financial statements   Minutes of board meetings (last 12 months)   Organizational chart   Offering or prospectus documents (if applicable)

Beneficiary / Payee Information

Although D&O proceeds are paid in accordance with policy terms, provide a primary payee or beneficiary for payment of insured loss amounts where applicable.

Declarations, Representations and Consent

The undersigned declares that the information contained in this application and in any attachments is true, correct and complete to the best of the signatory's knowledge. The Applicant acknowledges that the insurer will rely on the statements contained herein in determining eligibility for coverage and in establishing terms, conditions and premiums. Failure to disclose any material fact or the making of a material misrepresentation may result in rescission of coverage, denial of claims and/or retention of premiums.

The Applicant authorizes the insurer, its representatives and any investigating parties to make inquiries and obtain relevant records and information from any person or entity for underwriting or claim handling purposes, including prior carriers and regulatory authorities. This authorization shall survive termination of any policy issued in reliance on this application to the extent permitted by law.

The execution of this application does not bind the insurer to issue, nor the applicant to accept, insurance. Coverage, if issued, will be subject to the terms and conditions of the policy, endorsements and any applicable exclusions and limitations.

Fraud Warning: Any person who knowingly presents false information in an application may be subject to civil or criminal penalties under applicable law.

Certification and Signature

The undersigned representative certifies that they are authorized to complete this application on behalf of the Applicant, that the statements herein are true and complete, and that they understand and agree to the declarations, representations and consent above.

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