Insurance D&O Proposal Form

INSURANCE D&O PROPOSAL FORM

Date of Proposal:   Broker or Producer:

1. INSURED / APPLICANT INFORMATION

Corporation LLC Partnership Other  If Other, specify:

2. POLICY DETAILS (PROPOSED)

Coverage Form: Claims-made Occurrence   Requested Effective Date:   Requested Expiration Date:

Requested Extensions (check all that apply):  Side A (Non-Indemnifiable Directors & Officers) Side B (Company Reimbursement) Side C / Entity Coverage EPL (Limited)

3. CORPORATE ORGANIZATION & OPERATIONS

Does the organization have subsidiaries? Yes No   If yes, indicate number of subsidiaries:

4. LIST OF DIRECTORS & OFFICERS (PRINCIPAL)

Provide principal officers and directors. Attach complete roster if more space is required.

5. UNDERWRITING QUESTIONS — PLEASE ANSWER EACH ITEM

1. Has any claim, demand or suit been made against the organization or any past or present director or officer in the last five years?    Yes No

2. Is the organization aware of any facts, circumstances or incidents that might reasonably be expected to give rise to a claim?    Yes No

3. Has the organization or any director/officer declared bankruptcy, been adjudicated insolvent, or entered into receivership within the last five years?    Yes No

4. Have there been any acquisitions, divestitures, joint ventures or reorganizations in the last 36 months which materially affect assets or liabilities?    Yes No

6. EXCLUSIONS / PRIOR ACTS

The policy to be issued will contain standard exclusions including, without limitation, fraud/criminal acts by insured persons, bodily injury/property damage, and contractual liability beyond indemnification obligations. A Prior Acts exclusion or prior-known-facts exclusion may apply based upon the retroactive date. Applicant must disclose all known facts that could give rise to a claim.

Applicant acknowledges review of exclusions and confirms accuracy of disclosures:    Acknowledged

7. ATTACHMENTS CHECKLIST

Please attach the following documents where applicable and indicate below:

Financial statements (most recent fiscal year)

Loss runs / claims history (last 5 years)

Corporate bylaws / charter

Schedule of pending or prior litigation

Other (specify in Additional Information)

8. DECLARATION AND AUTHORIZATION

The undersigned authorized officer declares that the information contained in this proposal and all attachments is true and complete to the best of the undersigned's knowledge. The submission of this proposal does not bind the proposer to purchase, nor the insurer to issue, coverage. The proposer agrees that this proposal and any attachments shall form the basis of any policy issued.

The undersigned further represents that the organization has made all reasonable inquiries of its directors, officers and senior management to obtain the information required by this proposal form. The undersigned authorizes the release of claims history and financial information to insurers and their authorized representatives for the purpose of underwriting the requested coverage.

Warning: Any person who, with intent to defraud or knowing that they are facilitating a fraud against an insurer, submits an application containing a false statement may be guilty of insurance fraud under applicable law.

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