QUICKQUOTE ONLINE APPLICATIONS

Management Liability

Directors and Officers (D&O)
Employment Practices (EPLI)
Fiduciary
Crime and Fidelity

1. Name of Company:
Principal Address:
 
2. (a) Date since the Company has continuously carried on business:
(b) State of Incorporation: Date of Incorporation:
(c) Nature of business:
 
3. Officer designated to receive notices pertaining to this insurance:
 
4. Stock Ownership:
(a) Number of common shares outstanding:
(b) Number of common stock shareholders:
(c) Number of common shares owned (directly and beneficially) by directors:
(d) Number of common shares owned (directly and beneficially) by officers who are not directors:
(e) Name and percentage of holdings of any shareholder owning 5% or more of the common shares (directly or beneficially):
(f) Describe fully any other securities that are convertible to common stock:
 
5. (a) Latest Moody’s or Standard and Poor’s bond rating:
(b) Has this rating changed in the last 12 months? Yes No
(If Yes, please attach full details).
 
6. Has the Company under consideration at the present time or has it considered within the
last 6 months or does it contemplate any acquisitions, leveraged buyouts, tender offers
or mergers? Yes No
(If Yes, please attach full details).
 
7. Has the Company filed or contemplated filing any registration statement with the
Securities and Exchange Commission within the past 18 months or within the next 12 months for a public offering for securities? Yes No
(If Yes, please attach full details including copy of prospectus or registration statement).
 
8. (a) Within the last 18 months has the Company or any of its subsidiaries made or joined
in a Schedule 13-D filing with the Securities and Exchange Commission with respect to the ownership of the securities of another corporation? Yes No
(b) Is the Company aware that any person, corporation, or other entity has made a
Schedule 13-D filing with respect to the ownership of the Securities of the Company or any of its subsidiaries? Yes No
(If Yes to either of the above, please furnish copies of all filings.)
 
9. Is coverage proposed for directors and officers of subsidiaries? Yes No
(If Yes, please attach a separate sheet listing the name of each subsidiary, the date acquired or created, the percentage of ownership by the Company, any minority shareholders and type of operation.)
 
10. Has the Company or any of its directors or officers been involved in any of the following:
(a) any anti-trust, copyright or patent litigation? Yes No
(b) any civil or criminal action or administrative proceeding charging a violation of any federal or state security law or regulation? Yes No
(c) any representative actions, class actions or derivative suits? Yes No
(If Yes, please attach full details).
 
11. Present and prior insurance:
(a) Please give details of all directors and officers liability insurance carried for the last five years:
Insurer Limit Retention Premium Policy Period
(b) Have any loss payments (including defense costs) been made under any prior or current directors and officers liability policy or similar insurance, including under the self insured retention? Yes No
(c) Has any Insurer declined, canceled or non-renewed any policy or application for
directors and officers liability or similar insurance? Yes No
(d) Has the Company or any director or officer given written notice under the provisions of any prior or current directors and officers liability insurance of specific facts or circumstances which might give rise to a claim being made against any director or officer? Yes No
(If Yes to any of the above, please attach full details).
 
12. Other than as requested in question 10, has any claim been made against any director or officer which would have fallen within the scope of the coverage now applied for? Yes No
(If Yes, please attach full details).
 
13. Is any person proposed for coverage cognizant of any facts or circumstances (a) which he or she has reason to suppose might afford valid grounds for any future claim(s) such as would fall within the scope of the proposed coverage or (b) which indicate the probability of any such claim(s)? Yes No
(If Yes, please attach full details).
 
14. Is the Named Assured seeking Employment Practices coverage? Yes No
If yes, please answer the following questions.
 
15. Total number of employees (full-time and part-time).
Exact number, if over 500
 
16. Do more than 25% of all employees currently earn more than $50,000? Yes No
 
17. Have more than 25% of the officers or management voluntarily left the employ of the Assured Organization or had employment with the Assured Organization terminated within the last 18 months? Yes No
If yes, please provide details.
 
18. Does the Assured Organization anticipate in the next 12 months, or has the Assured Organization transacted in the last 12 months, any plant, facility, branch or office closing, consolidations or layoffs affecting 20% or more of the employees of the Assured Organization? Yes No
If yes, please provide details.
 
Describe the internal controls the Company maintains for Employment Practices.
 
19. Have all management staff and officers attended training and education programs on sexual harassment within the last 18 months? Yes No
 
20. Does labor relations counsel review the employment policies/procedures at least annually? Yes No
 
21. Is there a separate Human Resources Department? Yes No
 
22. Does the Assured Organization publish and distribute an employee handbook to every employee? Yes No
 
23. Are there written procedures for handling employee complaints of discrimination or sexual harassment? Yes No
 
24. Are there written procedures for handling employee grievances or complaints?
Yes No
 
25. Is the Named Assured seeking Fiduciary coverage? Yes No
If yes, please answer the following questions.
 
26. Does the Assured Organization have more than five (5) plans to be covered under the proposed insurance? If yes, please provide details on a separate page. Yes No
 
27. Indicate the type of plans to be insured.
Pension Welfare Benefit Profit Sharing Employee Stock Ownership
 
28. Total number of employees currently enrolled in all plans:
Exact number, if over 500
 
29. Total asset value of all plans combined for the most recent fiscal year.
 
30. Do all of the plans conform to the standards of eligibility, participation, vesting and other provisions of the Employee Retirement Income Security Act of 1974, as amended? Yes No
 
31. Are the plans reviewed at least annually to assure that there are no violations of any plan trust agreements, prohibited transactions or party in interest rules? Yes No
 
32. Are any of the plans under funded by more than 30%? If yes, please provide details on a separate page. Yes No
 
33. Does the Assured Organization have any delinquent contributions to any plan? If yes, please provide details on a separate page. Yes No
 
34. Have any plans been terminated, suspended, merged or dissolved within the last 24 months? If yes, please provide details on a separate page. Yes No
 
35. Does the Assured Organization anticipate terminating, suspending, merging or dissolving any plans within the next 18 months? If yes, please provide details on a separate page. Yes No
 
36. Are more than 10% of the assets of any plan, other than an Employee Stock Ownership Plan, invested in any securities of or loan to the Assured Organization? If yes, please provide details on a separate page. Yes No
 
37. Is the Named Assured seeking Crime/Fidelity coverage? Yes No
If yes, please answer the following questions.
 
38. Total number of employees:
Exact number, if over 500
 
39. Number of officers and employees who handle, have custody or maintain records of money, securities or other property:
 
40. Is there an annual audit or review performed by an independent CPA on the books and accounts, including a complete verification of all securities and bank balances?
 Yes No 
 
41. Are bank accounts reconciled by someone not authorized to deposit or withdraw from those accounts? Yes No
 
42. Is counter signature of checks required? Yes No
 
43. Is the applicant seeking Employee Benefit Plan Crime coverage? Yes No
 
44. Are pre-authorized controls maintained for all programmers and operators?
 Yes No
 
45. Do audit practices include tests to detect unauthorized programming changes?
 Yes No
 
46. Are computerized check writing operations segregated from departments that authorize checks? Yes No
 

47. The following materials regarding the applicant must be attached to this Application as applicable: fax them to 910.509.9006 - attention D&O
(a) The Company’s latest financials (audited if available)
(b) A copy of the Company’s indemnification provisions or by-laws,
(c) The Company’s product brochures,
(d) List of Board Members with their outside affiliations.
(e) Most recent EEO-1 (If applying for Employment Practices Insurance)
(f) Most recent form 5500 for 401k, or audit report on ESOP

 


1430 COMMONWEALTH DRIVE
WILMINGTON, NORTH CAROLINA 28403
(910) 509-9000