Insurance D&O EOI Form

INSURANCE D&O EOI FORM

Applicant / Insured Information

Policy Details and Requested Coverage

Requested Coverage Type: Claims-made Occurrence Run-off

Proposed Policy Period: From to . Retroactive Date (if applicable):

Requested Coverage Components (select all that apply):

Side A - Non-Indemnifiable Loss of Directors & Officers
Side B - Company Reimbursement
Side C - Entity Liability
Employment Practices Liability (EPL)
Fiduciary Liability
Other (describe below)

Directors & Officers Proposed for Coverage

Provide details for each director/officer proposed. Attach additional sheets if needed.

If there are additional directors/officers to propose, attach a signed schedule with the same detail as above.

Underwriting and Loss History

In the past five (5) years, has any proposed insured been subject to any claim, suit, demand, notice of investigation, regulatory proceeding, or written allegation of wrongdoing? Yes No

In the past seven (7) years, has any proposed insured been the subject of indictment, arraignment, arrest, plea, plea bargain, conviction, or entered into any consent order with any governmental or regulatory authority? Yes No

Has any insurer refused, cancelled, or non-renewed D&O insurance for the applicant or any proposed insured? Yes No

Corporate and Transactional Information

Has the applicant experienced, or is it contemplating, any merger, acquisition, divestiture, bankruptcy filing, insolvency, or receiver appointment in the past three (3) years or proposed for the next 12 months? Yes No

Exclusions and Acknowledgements

The proposed policy will contain standard exclusions including, without limitation, claims arising from: (a) knowingly fraudulent or criminal acts; (b) bodily injury or property damage; (c) certain ERISA/fiduciary matters except where specific fiduciary coverage is purchased; (d) pollution and war risks unless specifically endorsed; and (e) prior knowledge/claims asserted prior to the policy inception or outside the reporting period. The inclusion, scope and wording of any exclusion will be determined by the insurer and set forth in the final policy.

Beneficiary Designation

Designate beneficiaries for any coverages that allow payment to a beneficiary upon the death of an insured individual.

Document and Attachment Checklist

Please attach the following where applicable. Check each item that is included with this submission:

Most recent audited financial statements
Loss runs / claims history
Prior policy declarations / policy wording
Recent board minutes / governance documents
Resumes / bios of proposed insureds

Declaration and Authorization

The undersigned declares that the statements and particulars set forth in this form and any attachments are true and complete to the best of the undersigned's knowledge and belief. The undersigned acknowledges that information provided in this form shall be relied upon by the insurer in determining whether to extend coverage and in setting policy terms. The undersigned further acknowledges that any material misrepresentation, omission or concealment may be grounds for denial of coverage, rescission of coverage or refusal of claim payments in accordance with the applicable policy terms and law.

Authorization: The applicant (on behalf of all proposed insureds) authorizes any person or entity to provide to the insurer, its representatives or authorized service providers, information or records reasonably requested in connection with this application including, but not limited to, claim information, financial records, and regulatory or disciplinary history. A photocopy or electronic reproduction of this authorization shall be as valid as the original.

IT IS UNDERSTOOD AND AGREED that completion of this evidence of insurability form does not bind coverage. Coverage, if issued, will be subject to the terms, conditions, limitations and exclusions of the issued policy and any endorsements attached thereto.

Acknowledgement of Accuracy

By signing below, the undersigned certifies that he or she is authorized to bind the applicant and the information provided in this form is accurate and complete as of the date of signature. The undersigned acknowledges duty to notify the insurer of any material change in circumstances between the date of this application and the effective date of coverage.

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