Insurance General Liability & Directors and Officers Policy Form

INSURANCE GENERAL LIABILITY & DIRECTORS AND OFFICERS POLICY FORM

1. APPLICANT / INSURED INFORMATION

Applicant Name:

Individual    Corporation    LLC    Partnership    Non-profit    Other:

2. POLICY DETAILS

Policy Number:

Policy Period From: to

General Liability    Directors & Officers (D&O)    Combined GL & D&O    Other:

3. LIMITS, DEDUCTIBLES & PREMIUM

Retroactive Date (D&O if applicable):

4. COVERAGE OPTIONS (SELECT APPLICABLE)

Bodily Injury & Property Damage Liability — Covers sums the Insured becomes legally obligated to pay because of bodily injury or property damage.

Personal & Advertising Injury — Covers claims of libel, slander, false arrest, invasion of privacy and related offenses arising from advertising.

Products-Completed Operations — Covers liability arising out of products or completed work.

Defense Costs — Costs of defense are payable in addition to the limit, unless otherwise stated in the policy.

Employment Practices Liability — Covers claims alleging wrongful termination, discrimination, harassment, or other employment-related practices.

Fiduciary Liability — Covers wrongful acts in the administration of employee benefit plans.

5. EXCLUSIONS (STANDARD)

The policy shall not provide coverage for the following, except as may be added by endorsement: (a) Intentional acts or fraudulent conduct by Insured; (b) Claims arising out of pollution, unless specifically endorsed; (c) War, invasion, or nuclear risks; (d) Asbestos and lead liabilities; (e) Claims arising from bodily injury or property damage which are expected or intended by the insured; (f) Prior known claims or circumstances disclosed to the Insurer prior to inception of the policy period.

Applicant acknowledges receipt and review of the foregoing exclusion summary: Yes

6. PRIOR CLAIMS / LOSS HISTORY

Has any claim, suit, or proceeding been made against the applicant or any proposed insured in the past five (5) years? Yes    No

7. BENEFICIARY / INDEMNITY INFORMATION (D&O)

Does the entity indemnify directors and officers for claims arising from their corporate capacity? Yes    No

8. ATTACHMENTS / ENDORSEMENTS

Attachments submitted with this application (check all that apply):
Financial Statements    Bylaws / Charter    Prior Policies / Declarations
Loss Runs / Claims History    Resumes / CVs of Named Insureds    Other:

9. DECLARATIONS, REPRESENTATIONS & CERTIFICATION

The Applicant hereby declares that the information provided in this application and in all attachments is true, complete and accurate to the best of Applicant's knowledge. Applicant understands that the insurer will rely upon this information in deciding whether to issue the policy and on what terms. Applicant further acknowledges that any material misstatement, omission, or misrepresentation may be grounds for denial of coverage or rescission of the policy.

By signing below, Applicant authorizes release of records to the insurer for the purposes of underwriting and claim investigation, certifies that no information material to the insurer's risk assessment has been withheld, and agrees that this application and attachments shall form the basis of any policy issued.

It is unlawful to make a material misstatement or misrepresentation to obtain insurance coverage. Such acts may constitute insurance fraud and are subject to civil and criminal penalties under applicable law.

Applicant affirms that the statements contained herein are true and that no other material information has been omitted: Affirmed

10. NOTICE OF CLAIMS PROCEDURE

In the event of an occurrence which may give rise to a claim under the policy, the Insured shall provide prompt written notice containing details of the event, claim or suit to the Insurer in accordance with the policy provisions. Failure to provide timely notice may prejudice coverage to the extent permitted by law.

11. GOVERNING LAW & MISCELLANEOUS

This application and any resulting policy shall be governed by the laws of the state specified in the policy declarations. No change to the terms of coverage shall be effective unless made by written endorsement signed by an authorized representative of the insurer.

The Insurer shall have the right to investigate and settle claims as set forth in the policy. Defense costs and settlement payments shall be handled pursuant to the policy terms, including any duty to defend or to indemnify.

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