Directors & Offciers Liability Insurance


Proposal Form

Management Liability Insurance for Private Companies

This proposal form is ONLY suitable for companies:

where the Company or any of it’s subsidiaries are not listed on any stock market;

where the Company is not financial institution (i.e. bank, fund manager, property investment fund, brokerage house, etc.);

where total assets / total sales of the Company is up to € 100m.

Please answer all of the questions, leave no blank spaces.

Proposer Details

1.  Name of Company:

2.  Address of Head Office:

3.  Please answer for the following questions:

a) How long has the Company continually carried on business? Since ……….

b) Please state the business activities of the Company and its subsidiaries: ……………….

4.  a) Please list 5 largest shareholders of the Company and the percentage held by each (if the Proposer has mother company outside the country, please provide us with details on the mother company, such as country and address):

i)

ii)

iii)

iv)

v)

b) Total number of shares held by Directors and Officers (both direct and beneficial):

5.  Does the Company have any assets, activities or subsidiaries
in North America? qYes qNo

6.  Does the Company or any Director or Officer have Directors
& Officers Liability Insurance currently in force? qYes qNo
If “yes” please state:

a) Insurer:

b) Indemnity Limit:

c) Expiry Date:

Section 2 – only applicable if the principal activity of the Company is in IT, e-commerce, Telecommunication, Biotechnology, Mining or Pharmaceutics or the Company has any assets, activities or subsidiaries in North America.

7.  During the last three years has:

a) the name of the Parent Company changed? qYes qNo

b) any acquisition or merger taken place? qYes qNo

c) any subsidiary company been sold or ceased trading? qYes qNo

d) the capital structure of the Parent Company changed? qYes qNo
If “yes” please give details:

8.  Please give the total gross assets of the Company in North America:

9.  a) Please list all subsidiaries in North America:

b) For those subsidiaries in North America that are not wholly owned please list
who owns the minority stock:

The following questions are to be completed by all applicants

Claims Information

10.  Have claims ever been made against any past or present
Director or Officer of the Company or its subsidiaries? qYes qNo
If “yes”, please give details:

11.  Is the Proposer aware, after enquiry, of any circumstance or
incident which may give rise to a claim? qYes qNo
If “yes”, please give details:

Indemnity Limit

12.  Amount of Indemnity required:

Option 1. / Option 2. / Option 3.
Indemnity Limit

Signing this proposal does not bind the proposer to complete this insurance.

Declaration

It is declared that to the best of the knowledge and belief of the insured the statements and replies set out herein are true and that no material facts have been misstated or suppressed after enquiry. The insured undertake to inform insurers of alterations to any facts which are or thereby become material before inception of the contract of insurance.

A material fact is one which would influence the acceptance or assessment of the risk.

Signed:

Title:

(authorized signatory of the insured)

Company:

Date:

Please enclose with this Proposal Form

The last two Annual Reports and Accounts for the Company

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