DIRECTORS & OFFICERS LIABILITY Name of Organization * Contact Name * First Name Last Name Phone * (###) ### #### Email * Organization Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Website http:// Describe the Organization's Operations: * Annual Salary/Wages Expense * Total Assets * Do you have subsidiaries? * COVERAGE IS NOT AUTOMATICALLY PROVIDED FOR ALL SUBSIDIARIES. TERMS AND CONDITIONS OF COVERAGE FOR SUBSIDIARIES ARE DETAILED IN SECTION III OF THE POLICY. Yes No Is the Organization or any of its Subsidiaries involved in or presently considering any merger, consolidation, acquisition, divestment or sale of a portion of its business or has a similar transaction been considered or completed within the last three years? * Yes No Does the Organization or any proposed Insured perform, or are they involved in, any of the following? * Check those that apply. Services involving Children Collective Bargaining or Labor Advocacy Mental Health / Rehabilitation Counseling Medical Services Legal or Arbitration Services Teacher / Educator Financial Counseling Broadcasting / Publishing Lobbying Insurance or Investment Advisor Foster Care / Adoption Research & Development Other Professional Services Does the Organization take any disciplinary action or recommend disciplinary action as a result of credentials certification, accreditation, licensing, peer review or standard setting activities? * Yes No Date of Formation * MM DD YYYY Tax Status * Taxable Tax Exempt 501(c) Have there been during the last five years, or are there now pending, any civil, criminal, administrative or arbitration proceedings (including any proceeding initiated before the Equal Employment Opportunity Commission) brought against the Organization, its Subsidiaries, the Plans of the Organization or its Subsidiaries, or any person proposed for this insurance in their capacity as either Director, Officer, Trustee, employee, volunteer, or staff member of the Organization or its Subsidiaries? * If Yes, for each proceeding please email details of the complaint, the dollar amount of costs of defense and loss, the date the proceeding was filed, and whether the proceeding is open or closed. IT IS AGREED THAT ANY CLAIM ARISING FROM ANY PRIOR OR PENDING PROCEEDING IS EXCLUDED UNDER THE PROPOSED COVERAGE. Yes No Is the undersigned or any proposed insured aware of any fact, circumstance or situation involving the Organization or its Subsidiaries, the Plans of the Organization or its Subsidiaries, or any proposed insured which he or she has reason to believe might result in a future Claim? * If Yes, please email details. IT IS UNDERSTOOD AND AGREED THAT IF KNOWLEDGE OF ANY SUCH FACT, CIRCUMSTANCE OR SITUATION EXISTS, ANY CLAIM SUBSEQUENTLY ARISING THEREFROM SHALL BE EXCLUDED UNDER THE PROPOSED COVERAGE. Yes No Does the Organization currently have Directors' & Officers' and Employment Practices Liability Insurance? * Yes No If Yes, please provide the Insurance Company Name, Expiration Date, Limit of Insurance, Premium and Deductible or Retention Amount: * Has any Carrier (Insurance Company) cancelled or non-renewed similar coverage? * Yes No Please provide the number of employees (including officers) at the Organization * Provide the number of employees and officers whose employment has been involuntarily terminated IN THE LAST 12 MONTHS through layoffs, facility closings, individual employee terminations or similar circumstances: * Provide the number of employees and officers whose employment is expected to be involuntarily terminated IN THE NEXT 12 MONTHS through layoffs, facility closings, individual employee terminations or similar circumstances: * In the last twelve months, have there been any changes in the Executive Director or President position for reasons other than death, retirement at the normal retirement age or term limitations? * If yes, please email details Yes No DEFINED CONTRIBUTION PLANS (Including 401(K), 403(B), & 457 Plans): * Please enter the Total Asset Value for each of the Employee Benefit Plans (referred to as the Plans) sponsored by the Organization or its Subsidiaries for which coverage is desired. DEFINED BENEFIT PLANS (including Traditional Pension Plans): * Please enter the Total Asset Value for each of the Employee Benefit Plans (referred to as the Plans) sponsored by the Organization or its Subsidiaries for which coverage is desired. Has the organization or any Subsidiary terminatd or contemplated terminating any of the Plans within the past three years or within the next 12 months? * If Yes, please email details. Yes No Do any of the Plans fail to comply with the "Employee Retirement Income Security Act of 1974" (ERISA) where applicable? * If Yes, please email details. Yes No Has any Plan had, at any time during the last three years, a funding deficiency? * If yes, please email details. Yes No Electronic Signature of Executive Director * Date Signed MM DD YYYY It is agreed the particulars and statements contained in Proposal Forms submitted to the Insurer (and any material submitted therewith) are the representations of the Insured and are to be considered as incorporated in and constituting part of this Policy. It is also agreed this Policy is issued in reliance upon the truth of such representations. However, coverage shall not be excluded as a result of any untrue statement in the Proposal Form, except: * (1) as to any Insured Person making such untrue statement or having knowledge of its falsity; or (2) as to the Organization and any Subsidiary, if the person(s) who signed the Proposal Form(s) for this coverage or any Insured Person who is or was a past, present or future Chief Financial Officer, President, or Executive Director of the Organization made such untrue statement or had knowledge of its falsity. I AGREE Thank you for completing an application for Directors & Officers Liability Insurance. I will email you a quotation shortly. If you have any questions, please do not hesitate to contact me at (773) 972-1235 or Tom@fdean.com
