1.Please state:
a.The name of the Company......
b.The address of Head Office......
......
......
c.Country of Registration ......
- Company Registration No......
2.How long has the Company continuously carried on business
3.Principal Business Activities of the Company and its subsidiaries
......
4.During the past five years has -
a.The name of the Company has been changed?......
b.Any Acquisition or merger taken place?......
- Any Rights Issue taken place?......
- Any Subsidiary Company been sold or ceased trading?......
e.The capital structure of the Company changed?......
If so, please give full details ......
......
......
- Please give details of any change to the list of Directors and Officers given in the
Company's last annual report and accounts ......
6.a.Please give a complete list of all subsidiary companies including country of registration and percentage owned by Parent Organisation (other than shown in latest report and accounts)
......
......
......
b.Is coverage to include all subsidiaries?YES/NO
7.Please state:
a.The total number of Ordinary shares issued ......
b.The total number of Ordinary shareholders ......
c.The total number of Ordinary shares owned by Directors and Officers
(both direct and beneficial) ......
d.The name of shareholder and percentage holding of all shareholdings which
exceed 5% of the total ......
8.a.How long has the company continuously had Director’s and Officer’s Liability cover in force
b.Indemnity Limit required......
c.Expiry Date of the Policy......
9.Is the Company:
Listed on any U.K. stock exchange?......
Listed on any foreign stock exchange? - Please specify country and city
......
Traded in any other way? If so please specify ......
......
10.Please give total gross assets of the Group in North America (USA and Canada)
......
......
11.Please list those subsidiaries in North America that are not wholly owned together with
the Company's percentage interest in each......
For each subsidiary - Who owns the minority stock?......
12.Does the Company or any of its subsidiaries
i.Have any stock, shares or debentures in North America?......
ii.if YES,a)on what dates was the last offer/tender/issue made?
b)was the offer subject to The United States Securities Act of 1933
and/or The Securities Exchange Act of 1934 and/or any
amendments thereto?......
iii.Have any debt or equity instruments or commercial paper in North America?..
If so please give details......
......
iv.Have any shares traded in the form of American Depository Receipts? If so please give details including:-
a)Are they sponsored, if so by whom?......
b)What percentage do they represent of the total issued
Share Capital?......
c)The number of American Depository Receipt holders......
13.Please enclose a copy of the latest 20F filing made to the U.S.A. regulatory authorities
If not applicable please confirm......
14.Has any previous Policy for Directors’ and Officers’ Liability Insurance or Company
Reimbursement for Directors’ and Officers’ Liability Insurance been cancelled or, declined for renewal by any Insurer?
YES/NO
If YES please provide full details......
15.Have claims ever been made against any past, present Director or Officer of the Company or its subsidiaries that would fall within any similar insurance or has the company or its directors been subject to any Regulatory Enquiry in the past 6 years ?
YES/NO
If YES please provide full details......
16.Is the proposer aware after enquiry, of any circumstance or incident that may give rise to a claim under a Directors ‘& Officers’ liability policy
YES/NO
If YES please provide full details......
If known facts or circumstances exist, any claim or action arising from them will be excluded from the proposed coverage.
I declare, after enquiry, that to the best of my knowledge and belief the statements and particulars in this proposal are true and that no material facts have been mis-stated or suppressed.. I undertake to inform Insurers of any material alteration to those facts occurring before completion of the Contract of Insurance.
Signed......
Chairman/Chief Executive......
Company......
Date......
TE
Please submit with this proposal form:-
a)2 copies of the last two audited Annual Report and Accounts (if a renewal to us only 2 copies of the last audit Annual Report is required)
b)Latest Interim Statements
IMPORTANT NOTE
It is your duty to disclose all material facts to Insurers. A material fact is one which may influence Insurers’ judgement of the risk proposed. Failure to make such disclosure may prejudice your rights in the event of a claim, or allow Insurers to void the policy. If you are in any doubt about what may be considered a material fact, disclose it.
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