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PRIVATE COMPANY PROTECTION PLUS DIRECTORS AND OFFICERS & (Philadelphia Insurance Companies)

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RENEWAL APPLICATION FOR:
PRIVATE COMPANY PROTECTION PLUS
DIRECTORS AND OFFICERS & PRIVATE COMPANY LIABILITY INSURANCE
EMPLOYMENT PRACTICES LIABILITY INSURANCE
FIDUCIARY LIABILITY INSURANCE
NOTICE: THIS POL
ICY IS WRITTEN ON A CLAIMS MADE BASIS AND COVERS ONLY THOSE CLAIMS FIRST
MADE DURING THE POLICY PERIOD AND REPORTED IN WRITING TO THE UNDERWRITER PURSUANT TO
THE TERMS HEREIN. THIS POLICY PROVIDES A LIMIT OF LIABILITY AVAILABLE TO PAY JUDGMENTS OR
SETTLEMENTS THAT SHALL BE REDUCED BY AMOUNTS INCURRED AS DEFENSE COSTS. FURTHER
NOTE THAT DEFENSE COSTS PAID SHALL BE APPLIED AGAINST THE RETENTION AMOUNT.
• Whenever used in this Application the term Applicant shall mean the Named Corporation and its wholly-
owned/controlled Subsidiaries and their respective Directors, Officers, Trustees or Governors.
• The Applicant is required to complete Application Sections 1 and 5.
• The Applicant should complete the other applicable Section(s) for which coverage is desired. (See chart
below)
Check Coverage
Desired
Application
Section
Requested
Limit
Requested
Retention
Requested Effective
Date
General Information
1
N/A
N/A
N/A
Directors & Officers
2
$
$
Employment Practices
3
$
$
Fiduciary Liability
4
$
$
General Summary
5
N/A
N/A
N/A
SECTION 1 – GENERAL INFORMATION
1.
2.
3.
4.
Yes
No
5.
5A.
Risk Management Contact:
Risk Management’s Phone:
Risk Management Email:
INSTRUCTIONS
PI-PRD-Renewal App (06/11)
Page 1 of 8
© 2018 Philadelphia Consolidated Holding Corp.
08/2018
Clear Application
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SECTION II - DIRECTORS & OFFICERS INFORMATION
(Complete this section only if Directors & Officers Liability coverage is desired.)
6.
Ownership Information:
a.
Number of common shares outstanding:
If LLC, number of membership shares:
b.
Number of common shareholders:
Number of active members:
c.
Total number of shares owned directly or beneficially by Directors & Officers or Board of
Managers:
d.
Does any shareholder(s) or group of affiliated shareholders (including an
employee stock ownership plan) own more than five (5)% of the voting shares
directly or beneficially?
Yes
No
If yes, please provide details.
e.
Are there any changes in ownership from the prior year?
Yes
No
If yes, please provide details.
7.
Provide a list of all direct and indirect subsidiaries.
Name:
Type of Business:
Percent owned by the Applicant: %
Date Created/Acquired:
Name:
Type of Business:
Percent owned by the Applicant: %
Date Created/Acquired:
Name:
Type of Business:
Percent owned by the Applicant: %
Date Created/Acquired:
If additional space is needed, please attach a separate page or use the additional
information page provided at the end of the application.
8.
In the past twelve (12) months, does the Applicant anticipate being involved in any of
the following: If yes, provide details by attachment.
Merger, acquisition or consolidation with another entity?
Yes
No
Sales, distribution or divestiture of any assets other than in the ordinary course of
business?
Yes
No
Changes in the board of directors or senior management (other than death or
retirement)?
Yes
No
Change in the Applicant’s independent auditors?
Yes
No
9.
Offering of Securities Information
a.
Yes
No
Within the next twelve (12) months is the Applicant contemplating any private
offering of debt or equity of securities?
If yes, please attach the offering memorandum or prospectus describing the
essential terms of each transaction, including the effective date, the
professionals used, the amount of the offering and the current status of
each such transaction.
10.
Financial Information
a.
Within the next twelve (12) months, is the Applicant contemplating any
bankruptcy, reorganization or arrangement with creditors under federal or state
law?
Yes
No
b.
Is the Applicant in violation of any of its debts or loan convenants?
Yes
No
PI-PRD-Renewal App (06/11)
Page 2 of 8
© 2018 Philadelphia Consolidated Holding Corp.
08/2018
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c.
In the past twelve (12) months, did an Independent CPA render a “going concern”
opinion?
Yes
No
Note: If the Applicant answered yes to 10 (a), (b), or (c) please attach details
including the most recent financial audit, review or compilation with the auditors
notes.
11.
Outside Directorship
Does the Applicant direct or request any individual to serve as director, officer,
governor or trustee of any other entity?
If yes, please complete questions a – g below.
a.
Name of individual director, officer, governor or trustee:
Position held:
b.
Name of outside entity:
c.
Nature of entity’s business:
d.
Percentage of ownership by Applicant: %
Domestic or Foreign:
e.
Does the outside entity provide indemnification to its Directors and Officers?
Yes
No
f.
Complete the following information regarding the Directors and Officers
Liability Insurance carried by the outside entity: Insurer:
Limit of Liability: $
Policy Period:
g.
Has the outside entity or its Directors and Officers been involved in any Directors
and Officers Liability litigation?
Yes
No
SECTION III - EMPLOYMENT PRACTICES INFORMATION
(Complete this section only if Employment Practices Liability coverage is desired.)
12.
Please provide the following employee count information:
Number of employees per the following states:
CA:
FL:
NJ:
NY:
TX:
13.
Total number of current employees with annual compensation greater than $100,000:
14.
How many employees have been terminated or demoted in the past twelve (12)
months?
Voluntary:
Involuntary:
Laid Off:
15.
Is any reduction of employees or change of status anticipated or being contemplated in
the next year?
Yes
No
If yes, number estimated:
16.
Does the Applicant anticipate any plant, facility, branch, office, or department closing,
consolidation, reorganization or layoff in the next twelve (12) months?
Yes
No
If yes, provide details.
U.S. based employees:
Total Full Time:
Total Part Time:
Volunteers:
Temporary:
Leased:
Total Non U.S. based employees:
TOTAL SUM OF ABOVE:
Currently
One Year Ago Two Years Ago
PI-PRD-Renewal App (06/11)
Page 3 of 8
© 2018 Philadelphia Consolidated Holding Corp.
08/2018
Clear Application
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17.
Does the Applicant have a human resources department?
Yes
No
If no, describe how this function is handled.
18.
Human Resource Policies and Procedures
Has the Applicant implemented any new employment policies or procedures over the
past twelve (12) months?
Yes
No
If yes, please provide details.
SECTION IV - FIDUCIARY LIABILITY COVERAGE
(Complete this section only if Fiduciary Liability coverage is desired.)
19.
List all plans for which coverage is requested (use attachment if necessary):
Plan Name
Year
Established
Assets/
Contributions
Type*
Participants
Administrator
Example:
The ABC Manufacturing
Corp 401K Plan
2000
$1,000,000
3
75
self
a)
b)
c)
d)
*
1 = Employee Welfare Benefit Plan (as defined by ERISA)
2 = Defined Contribution Plan (as defined by ERISA)
3 = Defined Benefit Plan (as defined by ERISA)
4 = Other If “Type” is an ESOP a Fiduciary Liability - ESOP Supplement must be
completed.
If additional space is needed, please attach a separate page or use the additional information page
provided at the end of the application.
20.
Have there been any changes to any plan listed above?
Yes
No
If yes, provide details by attachment.
21.
Has any plan requested or contemplated filing a request for termination?
Yes
No
If yes, provide details by attachment.
22.
Has any plan been spun-off (sold), transferred or terminated?
Yes
No
If yes, provide details by attachment.
Please attach the most recent tax form 5500 for each plan listed above.
$
$
$
$
PI-PRD-Renewal App (06/11)
Page 4 of 8
© 2018 Philadelphia Consolidated Holding Corp.
08/2018
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SECTION V- GENERAL SUMMARY
(The Applicant must complete this section.)
23.
Please provide details on the following insurance coverage currently in place:
COVERAGES
Insurance Company
Limit of Liability
Deductible
Policy Effective
Dates
General Liability
Professional Liability
24.
Has the Applicant been the subject or involved in any litigation in the past twelve (12)
months?
Yes
No
If yes, provide details by attachment.
25.
In the next twelve (12) months, does the Applicant anticipate any substantial change
or reorganization of operations?
Yes
No
If yes, provide details by attachment.
Material Change
If there is any material change to the answers of this Application’s questions prior to the policy
inception date, the Applicant must notify the Underwriter in writing. Any outstanding quotation
may be modified or withdrawn.
False Information
PI-PRD-Renewal App (06/11)
Page 5 of 8
© 2018 Philadelphia Consolidated Holding Corp.
08/2018
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FRAUD STATEMENT AND SIGNATURE SECTIONS
The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge and belief and
after reasonable inquiry, that the statements set forth in this Application (and any attachments submitted with this Application) are true and
complete and may be relied upon by Company * in quoting and issuing the policy. If any of the information in this Application changes prior to
the effective date of the policy, the Applicant will notify the Company of such changes and the Company may modify or withdraw the quote or
binder.
The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.
*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company.
FRAUD NOTICE STATEMENTS
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE
CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL
THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THAT PERSON TO CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE
AFOREMENTIONED ACTIONS MAY CONSTITUTE A FRAUDULENT INSURANCE ACT WHICH MAY BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN
NEW YORK, THE CIVIL PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS ($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION).
(NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN, NM, OK, PA, RI, TN, VA, VT, WA AND WV).
APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR FRAUDULENT CLAIM FOR
PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY
OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN PRISON.
APPLICABLE IN COLORADO: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN INSURANCE
COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES, DENIAL OF
INSURANCE AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR
MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE
POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO
DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AGENCIES.
APPLICABL
E IN FLORIDA AND OKLAHOMA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A
STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY (IN FL, A PERSON IS
GUILTY OF A FELONY OF THE THIRD DEGREE).
APPLICABLE IN KANSAS: AN ACT COMMITTED BY ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE PRESENTED OR
PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER OR ANY AGENT THEREOF, ANY
WRITTEN, ELECTRONIC, ELECTRONIC IMPULSE, FACSIMILE, MAGNETIC, ORAL, OR TELEPHONIC COMMUNICATION OR STATEMENT AS PART OF, OR IN SUPPORT
OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY FOR PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR
PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY FOR COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN
MATERIALLY FALSE INFORMATION CONCERNING ANY FACT MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION
CONCERNING ANY FACT MATERIAL THERETO.
APPLICABLE IN KENTUCKY: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSONS FILES AN
APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION
CONCERNING ANY MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION
TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES OR A DENIAL OF INSURANCE
BENEFITS.
APPLICABLE IN PENNSYLVANIA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN
APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF
MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS SUCH
PERSON TO CRIMINAL AND CIVIL PENALTIES.
APPLICABLE IN NEW YORK: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN
APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF
MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SHALL BE
SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATE VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.
NAME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE
DIRECTOR)
____________________________________________________
SIGNATURE
DATE
SECTION TO BE COMPLETED BY THE PRODUCER/BROKER/AGENT
PRODUCER AGENCY
(If this is a Florida Risk, Producer means Florida Licensed Agent)
PRODUCER LICENSE NUMBER
(If this a Florida Risk, Producer means Florida Licensed Agent)
ADDRESS (STREET, CITY, STATE, ZIP)
PI-PRD-Renewal App (06/11)
Page 6 of 8
© 2018 Philadelphia Consolidated Holding Corp.
08/2018
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As part of t
his Application, please submit the following documents:
a) Applicant’s latest fiscal year end financial statement (CPA prepared) and latest interim financial
statement
b) List of the Applicant's current Directors & Officers
c) Copies of the most recently filed Form(s) 5500 (and attachments) for all ERISA plans for which coverage
requested (If Fiduciary Liability coverage is being requested)
THE INFORM
ATION CONTAINED IN AND SUBMITTED WITH THIS APPLICATION IS ON FILE WITH THE
UNDERWRITER AND ALONG WITH THE APPLICATION IS CONSIDERED PHYSICALLY ATTACHED TO AND
PART OF THE POLICY, SHOULD ONE BE ISSUED. THE UNDERWRITER WILL HAVE RELIED UPON THIS
APPLICATION AND ATTACHMENTS IN ISSUING ANY POLICY.
PI-PRD-Renewal App (06/11)
Page 7 of 8
© 2018 Philadelphia Consolidated Holding Corp.
08/2018
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ADDITIONAL INFORMATION
This page
may be used to provide additional information to any question on this application. Please identify
the question number to which you are referring.
__________________________________________
Signature Date
PI-PRD-Renewal App (06/11)
Page 8 of 8
© 2018 Philadelphia Consolidated Holding Corp.
08/2018
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Completed 7 November 2020

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