EVO GOLD NON-PROFIT MANAGEMENT LIABILITY INSURANCE

PROPOSAL FORM

(Claims madeand notified coverage)

This Proposal must be completed by a Partner or Director of the Firm.

All answers to the statements below must be affirmative “true” for the quotation to be valid and to bind coverage.

1.Name of the applicant:

Address:

2.Description of operations/services:

3.Annual operating budget: USA %: Foreign %: , country:

4.Number of employees: members: volunteers:

5.Name of pension plan if any:

6.The applicant, or any subsidiary, is a Canadian registered non for profit organization.TrueFalse

7.All the applicant’s employees, directors or officers are Canadian.TrueFalse

8.The applicant has been in business for at least 2 years.TrueFalse

9.In the last two consecutive years, the applicant published reports and accountsshowing net surplus.TrueFalse

10.The staff turnover is less than 25%.TrueFalse

11.In the past 5 years, there have been no claims made against the company or its directors or employees which may have been covered under this policy if it were in force.

TrueFalse

12.There have never been any proceedings (civil, criminal, insolvency, bankruptcy)Instigated against any person proposed for this insurance alleging misconduct or breaches of the law in their capacity as a director or officer of any company.

TrueFalse

13.In the past 5 years, the company has not suffered any direct financial loss exceeding $15,000. as a result of fraud or dishonesty committed by an employee.

TrueFalse

14.None of the directors or employees of the company are aware of:

a)any facts which might give rise to a claim being made against the company or its directors or employees which may be covered under this policy if it commences.

TrueFalse

b)any facts which would cause a reasonable person to think that the company might suffer a direct financial loss as a result of fraud or dishonesty committed by an employee.

TrueFalse

IMPORTANT

Disclosure of Material Facts

It is essential that every proposer or insured, when seeking a quotation, taking out or renewing an insurance, reveals to the prospective insurers any material facts or information (including any material circumstance) which might influence the judgment of an insurer in fixing the premium or in determining whether he will accept the risk. Failure to do so may render the contract of insurance voidable from inception at the option of the insurers and enable them to repudiate liability thereunder. If you have any doubt as to what constitutes a material fact or circumstance please do not hesitate to seek our advice.

I/We declare that the statements and particulars in this Proposal are True and that I/We have not mis-stated or suppressed any material facts. I/We agree that this Proposal together with any other information supplied by me/us shall form the basis of any Contract of Insurance effected thereon. I/We undertake to inform Underwriters of any material alteration to these facts occurring before completion of the Contract of Insurance.

Dated this...... day of...... 20….

Signature of Owner, Partner or Officer......

A COPY OF THIS PROPOSAL SHOULD BE RETAINED BY YOU FOR YOUR OWN RECORDS.