The Answer/corporate Directors & Officers Liability And Employment Practices Liability Application Form
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“The Answer”
CORPORATE DIRECTORS & OFFICERS LIABILITY AND EMPLOYMENT PRACTICES LIABILITY APPLICATION
ALL QUESTIONS MUST BE ANSWERED AND APPLICATION MUST BE SIGNED BY APPLICANT.
THIS IS AN APPLICATION FOR A CLAIMS MADE POLICY. PLEASE READ YOUR POLICY CAREFULLY.
Defense Costs shall be applied against the retention.
The Limits of Liability under the Directors and Officers Liability Coverage Part shall be reduced by, and may be
completely exhausted by, Defense Costs.
1.
Name of Organization ___________________________________________________________________________________________
Primary Address________________________________________________________________________________________________
Street
City
County
State
Zip
Web Site Address:_______________________________________
E-mail Address:______________________________________
2.
Description of operations _________________________________
Date Incorporated_____________________________________
3.
Are there any subsidiaries?
Yes
No
Please provide for each: Name, Date Established; Location; Operations; Ownership; Assets; Employees.
4.
Name and Title of Officer designated to receive all notices on behalf of all Insureds___________________________________________
5.
Current and Prior Insurance
D&O:
Co. _______________ Exp. __________ Premium ________________ Limits/Retention ____________________
EPL:
Co. _______________ Exp. __________ Premium ________________ Limits/Retention ____________________
E&O:
Co. _______________ Exp. __________ Premium ________________ Limits/Retention ____________________
Fiduciary:
Co. _______________ Exp. __________ Premium ________________ Limits/Retention ____________________
Crime:
Co. _______________ Exp. __________ Premium ________________ Limits/Retention ____________________
6.
Ownership. If any response is “Yes”, please explain fully in an attachment to this application.
a)
Number of shares outstanding. Voting _________________________________
Non Voting _____________________________
b)
Number shareholders or members. Voting_______________________________
Non Voting _____________________________
c)
Number of shares/interests owned by the directors and officers (direct and beneficial). _____________________________________
d)
Is the applicant a Subsidiary of another Organization?
Yes
No
Name of Parent. _____________________________________________________________________________________________
e)
Does any shareholder own 10% or more of the voting shares directly or beneficially
Yes
No
Please attach list of names and percentage ownership interest.
f)
Are there any other securities that are convertible to voting stock?
Yes
No
g)
Have any shares of the Organization been publicly traded within the last 3 years?
Yes
No
7.
Management. If “Yes”, please explain fully in an attachment to this application.
a)
Have there been any changes in the Board of Directors or Senior Management in
the past 3 years for reasons other than expiration of term, death or retirement?
Yes
No
b)
Has the Organization changed outside auditors in the last 3 years?
Yes
No
c)
Have any auditors found any material weaknesses in Organization's system
of internal controls?
Yes
No
d
Has the Organization violated or breached any debt covenant, loan agreement
or other material obligation in the past 3 years?
Yes
No
8.
Has the Organization in the past 36 months completed or agreed to, or does it contemplate within the next 12 months, any of the
following, whether or not such transactions are or will be completed?
If “Yes”, please explain fully.
a)
Merger, acquisition or consolidation with another entity?
Yes
No
b)
Sale, distribution or divestiture of more than 25% of assets or stock of the Organization?
Yes
No
c)
Any registration for a public offering?
Yes
No
d)
Any private placement?
Yes
No
e)
Reorganization or formal arrangement with creditors?
Yes
No
page 1 of 3
CD APP 8/05
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