EPACK Renewal Application

EPACK Renewal Application

NOTICE

With respect to all coverage parts, the policy you are applying for is a claims-made policy, and subject to its provisions, applies only to any claim first made during the policy period. No coverage exists for claims first made after the end of the policy period unless, and to the extent, the extended reporting period applies.

Defense costs, as well as any losses as defined in each applicable coverage part, reduce the limit of liability and are subject to the retention. Please review the policy carefully and discuss the coverage with your insurance agent or broker.

Applicants that answer “Yes” to questions asked below may require substantially different terms and conditions at renewal. Please provide detailed information to any questions answered “Yes” within the space provided at the end of this application. In addition, please attach the documents requested in the Specific Attachments Section.

I. GENERAL INFORMATION

1. a. The Applicant to be named in Item 1. of the Declarations (the Named Insured):

b. Street Address (no P.O. Box):

City: State: Zip:

Website Address:

c. Within past 12 months or during the next year does the Applicant plan on any actual or proposed merger, acquisition or divestiture? Yes No

d. Within the past 12 months or during the next year does the Applicant plan on creating or acquiring any new business, subsidiary or division? Yes No

e. Total number of locations for the Applicant and its Subsidiaries?

II. FINANCIAL INFORMATION

1. As of the most recent fiscal year-end, please provide the following information for the Applicant and Subsidiaries:

2. Within the last 12 months, has the Applicant’s or any Subsidiaries’ outside auditors rendered a “going concern” opinion? Yes No

3. Is the applicant or any Subsidiary currently or has it been in the past 12 months in violation of or has it amended any debt covenant? Yes No

III. INTERNAL CONTROLS

a. Within the last 12 months, has any outside auditors stated that there are weaknesses in the Applicant’s or any Subsidiaries system of internal controls? Yes No

b. Have there been any changes within the Applicant’s or Subsidiaries operations which require you to comply with Sarbanes-Oxley? Yes No

Have you voluntarily adopted or implemented Sarbanes-Oxley within your business practices? Yes No

IV. EMPLOYEE INFORMATION

a. What is the total number of full time employees for the Applicant and all

b. Part-time seasonal employees? Independent contractors? Volunteers?

V. REQUESTED LINES OF COVERAGE

Please answer this question only if the Applicant is applying for limits of insurance that exceed the expiring coverage currently written with CNA:

None of the individuals to be insured under any Coverage Part (the “Insured Persons”) have a basis to believe that any wrongful act, event, matter, fact, circumstance, situation, or transaction, might reasonably be expected to result in or be the basis of a future claim? Yes No

Without prejudice to any other rights and remedies of CNA, any claim arising from any facts circumstances, or situations required to be disclosed is excluded from the portion of any renewal limit of liability that exceeds the expiring limit of liability in the proposed insurance.

PLEASE ONLY COMPLETE THE QUESTIONS BELOW FOR THE LINES OF COVERAGE THE APPLICANT IS APPLYING FOR:

VI. DIRECTORS AND OFFICER LIABILITY

a. Over the past 12 months has there been any change in the Board Of Directors or senior management? Yes No

b. Has there been any changes in the number of shareholders; shareholders that own(ed) greater than a 5% interest within named company? Yes No

c. Does the Applicant or any Subsidiary plan on offering any private or public debt or equity offerings of securities? Yes No

VII. EMPLOYMENT PRACTICES LIABILITY

a. During the past 12 months has the Applicant or any Subsidiary made any amendments to any Human Resources policies, procedures or employee handbook? Yes No

Have you refrained from distributing the amendments to your employees? Yes No

b. Has the Applicant or any Subsidiary had any layoffs, staff reductions, facility closings, and or any other increase or decrease to the employment count of more than 15%; or are any planned over the next 12 months? Yes No

c. How many employees are highly-compensated individuals? ($100,000 or more per year)

d. How many employees are in the following jurisdictions? California Outside the U.S.

e. How many employees have left the Applicant or any Subsidiary over the past 12 months? Voluntary Involuntary

VIII. FIDUCIARY LIABILITY

a. In the past 12 months have there been any changes to any pension plan’s eligibility or have any plans (other than ESOP) invested more than 10% of the total plan assets in any security of, or loan to, the Applicant or in any real estate? Yes No

b. Has any plan been under-funded by more than 20%? Yes No

c. Has the Applicant or any Subsidiary created any new plans? Yes No

d. Have there been 401K matching contributions made in company stock? Yes No

f. In the past 12 months or within the next year does the applicant plan on terminating, suspending, merging, dissolving any pension plan(s) or converting such plan(s) into a cash balance plan? Yes No

IX. MISCELLANEOUS PROFESSIONAL LIABILITY

a. Has there been any change in the amount of work subcontracted out by the applicant? Yes No

b. Within the past 12 months has the Applicant’s four largest clients changed? Yes No

c. Does the Applicant expect any changes within the professional services that they provide? Yes No

d. Have there been any changes in the use of contracts or agreements with clients or subcontractors? Yes No

e. Within the past year, have you sued any customers for non-payment of contracts? Yes No

Specific Attachment Instructions

With in the space provided, please provide full details to any of the questions in which you answered “Yes”.

WARNING – ARKANSAS, COLORADO, FLORIDA, HAWAII, KENTUCKY, LOUISIANA, NEW JERSEY, NEW YORK, MAINE, OHIO, OKLAHOMA, PENNSYLVANIA AND VIRGINIA RESIDENTS ONLY

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

Please complete only if the Applicant is requesting an increase in their current limit of insurance. This Application must be signed by the Chairman of the Board, Chief Executive Officer or by the President.