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The Answer COMMITTED DIFFERENCE MAKING CCOORRPPOORRAATTEE DDIIRREECCTTOORRSS && (RT Specialty)

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COMMITTED
MAKING
TO
A
DIFFERENCE
1. Name of Applicant ________________________________________________________________________________________________________
Primary Address __________________________________________________________________________________________________________
Street City County State Zip
Web Site Address: ___________________________________________ E-mail Address:__________________________________________
2. Description of operations _____________________________________ Date Incorporated_________________________________________
3. Does the Applicant want any subsidiarie(s) covered? Yes No
Please provide for each: Name, Date Established; Location; Operations; Ownership; Assets; Employees.
4. Name and Title of Officer designated to receive all notices on behalf of all Insureds_______________________________________________
5. Current and Prior Insurance. Please provide insurer, expiration, premium, limits and retention, if known.
6. Financial Information. (A premium indication may be provided with this information).
7. Ownership. If any response is “Yes”, please explain fully in an attachment to this application.
a) Number of shares outstanding. Voting _____________________________________ Non Voting ________________________________
b) Number shareholders or members. Voting __________________________________ Non Voting ________________________________
c) Number of shares/interests owned by the directors and officers (direct and beneficial). _________________________________________
d) Is the applicant a Subsidiary of another Organization? Yes No
Name of Parent. _______________________________________________________________________________________________________
e) Does any shareholder own 10% or more of the voting shares directly or beneficially Yes No
Please attach list of names and percentage ownership interest.
f) Are there any other securities that are convertible to voting stock? Yes No
g) Have any shares of the Applicant been publicly traded within the last 3 years? Yes No
8. If “Yes”, please explain fully in an attachment to this application.
a) Have there been any changes in the Board of Directors or Senior Management in
the past 3 years for reasons other than expiration of term, death or retirement? Yes No
b) Has the Applicant changed outside auditors in the last 3 years? Yes No
c) Have any auditors found any material weaknesses in Applicant's system
of internal controls? Yes No
d Has the Applicant violated or breached any debt covenant, loan agreement
or other material obligation in the past 3 years? Yes No
CCOORRPPOORRAATTEE DDIIRREECCTTOORRSS && OOFFFFIICCEERRSS LLIIAABBIILLIITTYY AANNDD EEMMPPLLOOYYMMEENNTT PPRRAACCTTIICCEESS LLIIAABBIILLIITTYY AAPPPPLLIICCAATTIIOONN
All questions must be answered and application must be signed by the Chairperson of the Board or President of the Applicant.
TTHHIISS IISS AANN AAPPPPLLIICCAATTIIOONN FFOORR AA CCLLAAIIMMSS MMAADDEE PPOOLLIICCYY.. PPLLEEAASSEE RREEAADD YYOOUURR PPOOLLIICCYY CCAARREEFFUULLLLYY..
Defense Costs shall be applied against the retention.
TThhee LLiimmiittss ooff LLiiaabbiilliittyy uunnddeerr tthhee DDiirreeccttoorrss aanndd OOffffiicceerrss LLiiaabbiilliittyy CCoovveerraaggee PPaarrtt sshhaallll bbee rreedduucceedd bbyy,, aanndd mmaayy bbee
ccoommpplleetteellyy eexxhhaauusstteedd bbyy,, DDeeffeennssee CCoossttss..
CD APP 5/07
page 1 of 4
“The Answer”
D&O:
EPL:
E&O:
Fiduciary:
Assets Annual Revenues
Equity (Deficit) Annual Income (Loss)
Debt Retained Earnings (Loss)
Submit Application
9. Has the Applicant in the past 36 months completed or agreed to, or does it contemplate within the next 12 months, any of the
following, whether or not such transactions are or will be completed?
If “Yes”, please explain fully.
a) Merger, acquisition or consolidation with another entity? Yes No
b) Sale, distribution or divestiture of more than 25% of assets or stock of the Organization? Yes No
c) Any registration for a public offering? Yes No
d) Any private placement? Yes No
e) Reorganization or formal arrangement with creditors? Yes No
10. Total number of employees.
11. Is more than 20% of the Applicant's work force located in a state other than that shown in Item 1? Yes No
If yes, please provide the number of workers at each location.
12. Percentage of employees with total compensation including salaries, bonuses and commissions?
$76,000 to $100,000 ____________________ Over $100,000 ____________________
13. Has the Applicant closed any facilities, downsized, laid off or reduced staff in the past 12 months? Yes No
Does the Applicant anticipate doing so in the next 12 months? Yes No
If yes, please attach details.
14. Number of employees involuntarily terminated or laid off in the past 12 months? ____________________ past 24 months? _____________
15. Within the last 5 years has any employment related, third party harassment or third party discrimination claim, suit, inquiry, complaint or
notice of hearing been made against the Applicant or any individual proposed for Insurance? Yes No
If “Yes”, please complete a United States Liability Insurance Group claim supplement.
16. Within the last 5 years, has any claim, suit inquiry, complaint or notice of hearing been made against the Applicant or any person
proposed for Insurance in the capacity of Director, Officer, or Employee of the Applicant? Yes No
If “Yes”, please complete a United States Liability Insurance Group claim supplement.
17. Is any person or entity proposed for this Insurance aware of any fact, circumstance or situation which may result in a claim against the
Applicant or any of its Directors, Officers, or Employees? Yes No
If “Yes”, please complete a United States Liability Insurance Group claim supplement.
PPlleeaassee ccoommpplleettee tthhee ffoolllloowwiin
ngg iiff EEmmppllooyymmeenntt PPrraaccttiicceess LLiiaabbiilliittyy rreeqquueesstteedd::
18.
Does the Applicant have an Email/Internet Policy currently in place? Yes No
If no, is the Applicant willing to implement one? (Sample can be provided by the Company) Yes No
A premium credit will be applied for having, or agreeing to implement, an Email/Internet Policy.
Please submit a copy of current or newly implemented policy within 21 days after the inception date of this insurance.
Mandatory Written Employment Policies
.
Does the Applicant have an Anti-Discrimination and Anti-Harassment Policy currently in place? Yes No
If “yes”, does it include:
1. A definition of “Sexual Harassment” as well as Harassment in general? Yes No
2. At least two positions (e.g. President and HR Manager) to whom an Employee can report allegations of
Discrimination or Harassment? Yes No
3. Is it distributed to all Employees for them to read and then sign in acknowledgement? Yes No
If you answered “yes” to all of the above, you do not need to submit a copy to us.
CD APP 5/07
page 2 of 4
CCuurrrreenntt 1122 mmoonntthhss PPrriioorr 1122 mmoonntthhss
AAnnttiicciippaatteedd nneexxtt 1122 mmoonntthhss
((IIff ooppeerraattiinngg lleessss tthhaann 55 yyeeaarrss))
Full Time
Part Time
Temporary/Seasonal
Independent Contractors
Leased
If you do not have an Anti-Discrimination and Anti-Harassment Policy or answered “no” to any of the above, please (1) implement, (2)
distribute to all Employees and (3) forward to us such a policy containing the above provisions within 21 days after the inception
date of this insurance (sample can be provided by the Company). Failure to do so will result in rescission of the binder for this
insurance.
RREEQQUUIIRREEDD IINNFFOORRMMAATTIIOONN
A. Completed Application signed and dated by the President or Chairperson of the Board.
B. Most recent audited financial statement.
C. Any Private Placement Memorandum issued within the past 12 months.
NNeeww YYoorrkk DDiisscclloossuurree NNoottiiccee::
This policy is written on a claims made basis and shall provide no coverage for claims arising out of incidents,
occurrences or alleged wrongful acts that took place prior to the retroactive date, if any, stated on the declarations. This policy shall cover only
those claims made against an insured while the policy remains in effect and all coverage under the policy ceases upon termination of the policy
except for the automatic extended reporting period coverage unless the insured purchases additional extend reporting period coverage. The
policy includes an automatic 60 day extended claims reporting period following the termination of this policy. The Insured may purchase for an
additional premium an additional extended reporting period of 12 months, 24 months or 36 months following the termination of this policy.
Potential coverage gaps may arise upon the expiration for this extended reporting period. During the first several years of a claims-made
relationship, claims-made rates are comparatively lower than occurrence rates. The insured can expect substantial annual premium increases
independent overall rate increases until the claims-made relationship has matured.
MMiissssoouurrii aanndd AArrkkaannssaass DDiisscclloossuurree NNoottiicceess::
I under
stand and acknowledge that this policy contains a defense within the limits provision which
means that “defense costs” will reduce my limits of insurance and exhaust them completely. Should that occur, I shall be liable for any further
legal “defense costs” and damages. This provision applies to the directors and officers liability coverage part and also applies to the
employment practices liability coverage part if I have more than 200 employees or if my limits of liability are less than $500,000.
Signed and accepted by the insured: _____________________________________________________________________________________________
Signature of President or Chairperson
VViirrggiinniiaa NNoottiiccee::
You have an option to purchase a separate limit of liability for the extension period, Policy common conditions I. If you do not
elect this option, the limit of liability for the extension period shall be part of the and not in addition to limit specified in the declarations.
Statements in the application shall be deemed the insured’s representations. A statement made in the application or in any affidavit made
before or after a loss under the policy will not be deemed material or invalidate coverage unless it is clearly proven that such statement was
material to the risk when assumed and was untrue.
MMiinnnneessoottaa NNoottiiccee::
The clause “and/or authorization or agreement to bind the insurance.” is replaced with “Authorization or agreement to bind
the insurance may be withdrawn or modified based on changes to the information contained in this application prior to the effective date of the
insurance applied for that may render inaccurate, untrue or incomplete any statement made with a minimum of 10 days notice given to the
insured prior to the effective date of cancellation when the contract has been in effect for less than 90 days or is being canceled for
nonpayment of premium.
CCoolloorraaddoo FFrraauudd SSttaatteemmeenntt::
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
inf
ormation 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.
DDiissttrriicctt ooff CCoolluummbbiiaa FFrraauudd SSttaatteemmeenntt:: WWAARRNNIINNGG::
It is a crime to provide false or misleading information to an insurer for the purpose of
defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if
false information materially related to a claim was provided by the applicant.
FFlloorriiddaa FFrraauudd SSttaatteemmeenntt::
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 of the third degree.
KKeennttuucckkyy FFrraauudd SSttaatteemmeenntt::
An
y 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.
MMaaiinnee aanndd WWaasshhiinnggttoonn FFrraauudd SSttaatteemmeenntt::
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.
NNeeww JJeerrsseeyy FFrraauudd SSttaatteemmeenntt::
Any person who includes any false or misleading information on an application for an insurance policy is
subject to criminal and civil penalties.
NNeeww YYoorrkk FFrraauudd SSttaatteemmeenntt::
An
y 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 also be subject to a civil penalty not to
exceed five thousand dollars and the stated value of the claim for each such violation.
OOhhiioo FFrraauudd SSttaatteemmeenntt::
Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
OOkkllaahhoommaa FFrraauudd SSttaatteemmeenntt:: WWAARRNNIINNGG::
Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim
for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
page 3 of 4
CD APP 5/07
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PPeennnnssyyllvvaanniiaa FFrraauudd SSttaatteemmeenntt::
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.
TTeennnneesssseeee aanndd VViirrggiinniiaa FFrraauudd SSttaatteemmeenntt::
It is a crime to knowingly provide false, incomplete or misleading information to an insurance
company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
FFrraauudd SSttaatteemmeenntt ((AAllll OOtthheerr SSttaatteess))::
Any person who knowingly presents a false or fraudulent claim for
payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty
of a crime and may be subject to fines and confinement in prison.
Broker’s Signature _____________________________________________________________________________________________________________
Some states require that we have the Name and Address of your (Insured’s) Authorized Agent or Broker.
If the primary address of the location listed in item #1 is in the state of
NNeeww YYoorrkk,, IIoowwaa
or
FFlloorriiddaa
, the states of
NNeeww YYoorrkk
,
IIoowwaa
and
FFlloorriiddaa
require that we have the names and address of your (insured’s) authorized Agent or Broker.
Name of Authorized Agent or Broker _____________________________________________________________________________________________
Address: ______________________________________________________________________________________________________________________
Mail complete application through local Agent or Broker to:__________________________________________________________________________
______________________________________________________________________________________________________________________________
The undersigned represents that to the best of his/her knowledge and belief the particulars and statements set forth herein are true and agree
that those particulars and statements are material to the acceptance of the risk assumed by the Company. The undersigned further declares
that any claim, incident or event taking place prior to the effective date of the insurance applied for which may render inaccurate, untrue, or
incomplete any statement made will immediately be reported in writing to the Company and the Company may withdraw or modify any
outstanding quotations and/or authorization or agreement to bind the insurance. The signing of this Application does not bind the undersigned
to purchase the insurance, nor does the review of this Application bind the Company to issue a policy. It is understood the Company is relying
on this Application in the event the Policy is issued. It is agreed that this Application, including any material submitted therewith, shall be the
basis of the contract should a policy be issued and it will be attached and become a part of the policy.
Applicant’s Signature_____________________________________________ Title ________________________ Date______________________
(Chairperson of the Board or President)
CD APP 5/07
page 4 of 4
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The Answer COMMITTED DIFFERENCE MAKING CCOORRPPOORRAATTEE DDIIRREECCTTOORRSS && (RT Specialty)

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Completed 13 December 2020

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