Kemper Private Company Declarations: DJS Edits

PRIVATUS

(Including Directors, Officers and Corporate Liability, Employment Practices Liability, Fiduciary Liability and Outside Directorship Liability Insurance)

DECLARATIONS

THIS POLICY IS WRITTEN ON A CLAIMS MADE AND REPORTED BASIS AND COVERS ONLY CLAIMS FIRST MADE AGAINST THE INSUREDS DURING THE POLICY PERIOD OR THE EXTENDED REPORTING PERIOD, IF APPLICABLE, AND REPORTED IN WRITING TO THE INSURER WITHIN THE TIME AND PURSUANT TO THE TERMS HEREIN. THE LIMIT OF LIABILITY AVAILABLE TO PAY JUDGMENTS OR SETTLEMENTS SHALL BE REDUCED AND MAY BE TOTALLY EXHAUSTED BY AMOUNTS INCURRED AS DEFENSE COSTS. PLEASE READ THIS POLICY CAREFULLY.

COMPANY: / POLICY NUMBER:
Item 1. Parent Company:
______(Name)
______(Address)
______
______/ Item 2. Policy Period:
a. Inception Date
b. Expiration Date
Both dates at 12:01 a.m. at the
address listed in Item 1
Item 3. Limits of Liability:
(A) Maximum aggregate Limit of Liability for all Loss for all Claim(s)
under all Insuring Agreements during the Policy Period$ ______
(B)Maximum aggregate Sublimit of Liability for Internal Revenue
Service fines, penalties and sanctions under Insuring Agreement C
during the Policy Period $
Item 4.Retentions:
(A)Each Claim:
(i)under each Insuring Agreement A$ ______
(ii)under each Insuring Agreement B$ ______
(iii)under each Insuring Agreement C$ ______
(iv)under each Insuring Agreement D$ ______
(B)No Retention shall apply for non-indemnifiable Loss under Insuring Agreements A and D
Item 5.Extended Reporting Period:
(A) Additional Premium: _____ percent of annualized premium for the Policy Period
(B) Extended Reporting Period: One Year
Item 6. Insuring Agreements Included and Effective at Inception (check all that apply):
SectionI. Insuring Agreement A (D&O):Included
SectionI. Insuring Agreement B (EPL):Included
SectionI. Insuring Agreement C (Fiduciary):Included
SectionI. Insuring Agreement D (ODL):Included / Item 7.Third Party Claim Coverage Included?Yes No
Item 8.Pending and Prior Claim Date:
SectionI. Insuring Agreement A: ______
SectionI. Insuring Agreement B: ______
SectionI. Insuring Agreement C: ______
SectionI. Insuring Agreement D: ______/ Item 9.Continuity Date: ______
SectionI. Insuring Agreement A: ______
SectionI. Insuring Agreement B: ______
SectionI. Insuring Agreement C: ______
SectionI. Insuring Agreement D: ______
Item 10.Notices to Insurer:
Notice of Claim(s) or Circumstances To Be Sent To:All Other Notices To Be Sent To:
Axis Financial Insurance Solutions ClaimsAxis Financial Insurance Solutions
Address: Connell Corporate ParkAddress: Connell Corporate Park
Three Connell DriveThree Connell Drive
P.O. Box 357P.O. Box 357
Berkeley Heights, NJ 07922-0357 Berkeley Heights, NJ 07922-0357
Facsimile: (908) 508-4389Facsimile: (908) 508-4301
Item 11. Endorsements Effective at Inception: / Item. 12. Terrorism Coverage:
Coverage Purchased by ParentCompany: Yes No
If yes, Terrorism Coverage Premium: $

The Insurer has caused this Policy to be signed and attested by its authorized officers, but it shall not be valid unless also signed by another duly authorized representative of the Insurer.

______

Authorized Representative Date

PV 0100 (Ed. 0903)Page 2 of 2Page 2 of 2Printed in U.S.A.