MANAGEMENT LIABILITY INSURANCE

APPLICATION FORM

INTRODUCTION

The purpose of this application form is for us to find out who you are and to obtain information relevant to the cover provided by the ML policy. Completion of this application form does not oblige either party to enter into a contract of insurance.
Insurance is a contract of utmost good faith. This means that the information you provide in this application form must be complete, accurate and not misleading. It also means that you must tell us about all facts and matters which may be relevant to our consideration of your proposal for insurance. Any failure by you in this regard may entitle us to treat this insurance as if it never existed. If a contract of insurance is agreed between you and us this application form will form the basis of the contract.
Important: Insuring clauses 1, 2, 3 and 4 (SECTIONS A and B only) provide cover on a claims made and reported basis. Under these insuring clauses, a claim must be first made against the Insured and notified to us during the period of the policy and a claim will not be covered if it arises out of any prior or pending litigation before the Prior and Pending Date.

HOW TO COMPLETE THIS FORM

Whoever fills out the form must be a director of the applicant company and should make all the necessary inquiries of their fellow directors, officers and employees to enable all the questions to be answered.
If you require any extra space to complete the answers to questions contained within this application form please continue your response in the Additional Information section at the back of the form. Once you have completed the form please return it directly to your insurance broker.

SECTION 1: COMPANY DETAILS

1.1 Please provide the following details:

Insured company:*

Email*

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Year of establishment:*

Website:

* if less than 12 months old, please supply a copy of your business plan

1.2 Please state the legal status of the company (tick as appropriate):*

Corporation
Partnership
Sole Proprietorship
LLC
Other

If other, please provide details:

1.3 Is the company listed on any stock exchange or other securities market?*

Yes
No

If yes, does the company file the statutory File 40-f to the Securities and Exchange Commission?*

Yes
No

If you have ticked the shaded boxes above, please explain in the box below and continue on the ADDITIONAL INFORMATION page if necessary. Please also provide a copy of the completed statutory File40-f if applicable:

1.4 Please describe below the nature of your business activities (including your subsidiaries):

1.5 Please state the number of employees and business locations:

Number of employees (Canada):

Number of locations (Canada):

Number of employees (USA):

Number of locations (USA):

Number of employees (Europe):

Number of location (Europe):

Number of employees (Rest of the world):

Number of locations (Rest of the world):

1.6 Please advise the:

a) Number of shares issued:

b) Number of shareholders:

c) Name and percentage of shares owned by shareholders owning more than 10% of all voting rights (both direct and indirect):

Name	Percentage Ownership	Represented on the board ( Y / N ):

1.7 Please confirm:

a) Your gross revenue for the last completed financial year:*

b) The percentage of turnover derived from the USA:*

c) You achieved a profit for the last completed financial year:*

Yes
No

d) Your total assets for the last completed financial year:*

e) The percentage of assets within the USA:*

f) You have a positive net worth for the last completed financial year:*

Yes
No

1.8 Have you in the past 3 years, or do you during the next 12 months, have plans to:

a) Sell the company?*

Yes
No

b) Be involved in any mergers, acquisitions or divestments?*

Yes
No

c) Change your capital structure?*

Yes
No

d) Raise any new equity capital?*

Yes
No

If you have ticked any of the shaded boxes in questions1.7 – 1.8, please explain in the box below and continue on the ADDITIONAL INFORMATION page if necessary:*

Directors and Officers Liability Insurance

Step 1 of 8

MANAGEMENT LIABILITY INSURANCE

APPLICATION FORM

HOW TO COMPLETE THIS FORM

SECTION 1: COMPANY DETAILS

SECTION 2: EMPLOYMENT PRACTICES LIABILITY

SECTION 3: FIDUCIARY LIABILITY

SECTION 4: CYBER AND PRIVACY

SECTION 5: CRIME

SECTION 6: KIDNAP AND RANSOM

SECTION 7: INSURANCE REQUIREMENTS

SECTION 8: CLAIMS EXPERIENCE AND INSURANCE HISTORY

SECTION 9: DECLARATION

Name of Plan:	Plan assets:	Type of Plan (i.e. defined contributions or defined benefits, welfare benefit, profit sharing etc):

Location	Security

Country of destination	Number of employees travelling	Duration of visit