Private Company Directors and Officers Liability

Coverage Application

ThetermApplicantmeansallcorporations,organizationsorotherentities,includingsubsidiaries,proposedforthisinsurance.

1.ApplicantInformation:Name ofApplicant:Street Address:

City, State, ZIP Code:Website Address:

YearApplicant’s business was established:DescriptionofApplicant’soperations:

2.Applicant’s Standard IndustrialClassification (SIC)code, if known (4-digit number):

3.Is the Applicanta subsidiary of a foreign parent?YesNo

4.DoestheApplicant currently file, or does it anticipate filing in the next 6 months, anydocuments with the Securities and Exchange Commission or similarforeign authority regarding

anyequityordebt securities?YesNo

1.Total Number of Employees:

2.List and describe all entities in which the Applicant’sownership interest is50%orgreater orover which the

Applicanthas management control(Check here if not applicable):

Name / %
Owned / YearStarted / DescriptionofOperations / EntityType*
%
%
%
*EntityType:FP=For-Profit (other thanPartnership); NP=Non-Profit; GP=General Partnership;LP=LimitedPartnership; LLC=Limited LiabilityCompany

Toenter more information, pleaseattacha separatepage or an organizationchart with ownership detail.

3.In the next 12 months (or during the past24months) is theApplicantcontemplating (or hasthe Applicant completed or beenintheprocess ofcompleting) the following:

a. / Any actual orproposed merger, acquisition, or divestiture? / Yes / No
b. / Any creation ofanew business, subsidiary, or division? / Yes / No
c. / Any registration for a publicoffering or aprivate placement of securities (stocks orbonds)? / Yes / No
d. / Any reorganization orarrangement withcreditors under federal orstate law? / Yes / No
e. / Any branch, location, facility, office,or subsidiary closings,consolidations, or layoffs? / Yes / No

If any of the questions above were answered Yes, please attach anexplanation,including thetiming, theessentialterms oftheevent, arrangement, andthe surrounding circumstances.

Total Shares / Common / Preferred / Other
Authorized
Outstanding
Voting SharesOutstanding
Voting Shares OwnedbyDirectors andOfficers(Direct and Beneficial)
Number of Voting Shareholders
Ifthereare multiple classes ofstock, please attach a list.The list should include:Number of Shareholders andNumber of SharesHeld inEach Stock Class.
1. / Doesthe Charter orBy-laws of the Organization provide indemnification toitsDirectors andOfficersto the fullest extent permitted by law? / Yes / No
2. / Are there any securitiesthat are convertible tovotingstock?
If Yes, pleaseattach an explanation. / Yes / No
3. / Listall shareholders that own greaterthan 5% of any class of security:
Shareholder / Class ofSecurity / %Owned / Director orOfficer?
% / YesNo
% / YesNo
% / YesNo

If there are more Shareholders, pleaseattach a list.Thelist should include:Shareholder Name, ClassofSecurity(including voting and non-voting shares separately), %Ownedand indicate if they are a Director orOfficer.

4. / Is any shareholder a trust that qualifiedasan Employee StockOwnership Plan underERISA or holds securitiesfor the benefit of employees?
If Yes, please attach most recent stock valuation report. / YesNo
YesNo
5. / Have there been any changes in the Boardof Directors orSeniorManagement ofthe
Applicantwithin the past 3yearsforreasons other thandeath orretirement?
If Yes, pleaseattach an explanation.
6. / Aretherecurrently outstanding loans toany Director or Officer?
If Yes, pleaseattach an explanation. / Yes / No
IV. / FINANCIAL INFORMATION
1. / Is the Applicantcurrently (or has it been in the past24 months) inviolation of,or hasit received anamendment to any debt covenant?
If Yes, pleaseattach an explanation. / Yes / No

Note:Omit Question 2 if the Applicantis required to submit a separate financial statement as directed in the RequiredAttachments section.

2. Complete thefollowingchart providing the requested financial information:

Indicate thefollowing asit relatestothe Applicant’s fiscalyear end (FYE):
(Please indicate negative figures with“()”or“-”as appropriate) / MostRecent FYE(Month/Year)
(/_) / Prior FYE(Month/Year)(/_)
Current Assets / $ / $
Total Assets / $ / $
Current Liabilities / $ / $
Long Term Debt / $ / $
Retained Earnings(Accumulated Deficit/Fund Deficit) / $ / $
Net Equity/Net Assets(Deficit Equity) / $ / $
Revenues / $ / $
Net Income (Net Loss) / $ / $

1. Scope of financialstatement preparation:

2. / InternalCPA CompilationCPA ReviewCPA
Has theApplicantchanged outside auditors inthe last 3 years? / Audit
N/A / Yes / None
No
If Yes, pleaseattach an explanation.
3. / Have the outside auditorsstated there are material weaknesses intheApplicant’s
systemsofinternalcontrols?
If Yes, pleaseattach an explanation andprovide the latest CPA letter to managementand management’sresponse. / N/A / Yes / No
4. / Has theApplicantimplemented all material recommendations of the auditor?
If No, pleaseattach an explanation. / N/A / Yes / No
5. / Has any auditor issued a “going concern” opinionfor theApplicant’s financialstatements during the past3years?
If Yes, pleaseattach an explanation. / N/A / Yes / No
VI. / CURRENT INSURANCE INFORMATION/REQUESTED INSURANCE TERMS
RequestedLimit(A) / RequestedRetention(B) / RequestedEffective Date(C) / Coverage CurrentlyPurchased
(D)
$ / $ / YesNo
ExpiringLimit (E) / ExpiringRetention(F) / ExpiringPremium(G) / CurrentInsurer(H) / Date CoverageFirst Purchased(I)
$ / $ / $

1. What is theApplicant’s preference for defense coverage?Duty to DefendReimbursement

3. / If Liability Coverage isnot currently purchased asindicated inColumn (D) above,please answer the following question:
Isthe Applicantor any person proposed forthis insurance awareofanyfact, circumstance,situation, event or act that reasonably couldgive risetoaclaim against them under theLiability Coverage for which theApplicantis applying?
If Yes, pleaseattach an explanation. / Yes / No
4. / Ifthe Requested LimitinColumn (A) exceeds theExpiring Limit inColumn(E), please answerthe following question:
Solely with respect to any higher limits requested orthat may ultimately be issued for
the proposedinsurance, isthe Applicantorany person proposed for this insurance awareof any fact, circumstance, situation, event oract that reasonably could give riseto a claimagainst them under the Liability Coverage for which theApplicantis applying?
If Yes, pleaseattach an explanation. / Yes / No

Withrespecttotheinformationrequiredtobedisclosedinresponsetothequestionsabove,theproposedinsurancewillnotaffordcoverageforanyclaimarisingfromanyfact,circumstance,situation,eventoractaboutwhichanyexecutiveofficerof theApplicanthadknowledge priortotheissuanceofthe proposedpolicy,norforanypersonorentitywhoknewof such fact, circumstance, situation, event oract prior to the issuance of the proposed policy.

1. Has any person or entity proposed for thisinsurance been a party to any securitiesclaims,

Date ofSuchClaim / Nature ofClaim / Amount Paidfor Defense / Amount Soughtor Paid forDamages / Covered byInsurance? / CorrectiveProceduresImplemented / CurrentStatus
$ / $ / YesNo
$ / $ / YesNo

VIII.REQUIRED ATTACHMENTS

AspartofthisApplication,pleasesubmitthefollowingdocuments(thesedocuments,andtherepresentationsandfactsthey contain,aremade apartofthisApplication,whethersuchdocumentsarephysicallydeliveredtotheCompanybytheApplicantorare obtainedbythe Company fromany publicsource, including theInternet):

  • Most recent annual financial statement,iflimit requested is $2,000,000 or greater, or,Applicanthas been in businesslessthan3years
  • Listof Directors and Officers, if limit requested is$2,000,000 orgreater
  • Any Private Placement Memorandum orany documents filed with the Securitiesand Exchange Commission in thepastyear
  • Interim financial statementfor Development Stage companies
Attention: Insureds inArkansas, D.C., Louisiana, Maryland, New Mexico,and Rhode Island
Anypersonwhoknowingly(andwillfullyinD.C.andMD)presentsafalseorfraudulentclaimforpaymentofalossorbenefitorwhoknowingly(andwillfullyinD.C.andMD)presentsfalseinformationinanapplicationforinsuranceisguilty of a crime and maybe subject to fines and confinement in prison.
Attention: Insureds inColorado
Itisunlawfultoknowinglyprovidefalse,incomplete,ormisleadingfactsorinformationtoaninsurancecompanyforthepurposeofdefraudingorattemptingtodefraudthecompany.Penaltiesmayincludeimprisonment,fines,denialofinsurance,andcivildamages.Anyinsurancecompanyoragentofaninsurancecompanywhoknowinglyprovidesfalse,incomplete,ormisleadingfactsorinformationtoapolicyholderorclaimantforthepurposeofdefraudingorattemptingtodefraudthepolicyholderorclaimantwithregardtoasettlementorawardpayablefrominsuranceproceedsshall be reportedtothe Colorado Division ofInsurance within the Department of Regulatory Agencies.
Attention:Insureds inFlorida
Anypersonwhoknowinglyandwithintenttoinjure,defraud,ordeceiveanyinsurerfilesastatementofclaimoranapplicationcontaining any false, incomplete, or misleadinginformation is guilty of a felony of the third degree.
Attention: Insureds inKentucky, New Jersey, New York, Ohio, and Pennsylvania
Anypersonwhoknowinglyandwithintenttodefraudanyinsurancecompanyorotherpersonfilesanapplicationforinsuranceorstatementofclaimcontaininganymateriallyfalseinformationorconcealsforthepurposeofmisleading,informationconcerninganyfactmaterialtheretocommitsafraudulentinsuranceact,whichisacrimeandsubjectssuchpersontocriminalandcivilpenalties.(InNewYork,thecivilpenaltyisnottoexceedfivethousanddollars($5,000) andthestated value ofthe claim foreach such violation.)
Attention:Insureds inMaine, Tennessee, Virginia, and Washington
Itisacrimetoknowinglyprovidefalse,incomplete,ormisleadinginformationtoaninsurancecompanyforthepurposeof defraudingthe company.Penalties include imprisonment, fines,and denial of insurance benefits.
Attention: Insureds inPuertoRico
Anypersonwhoknowinglyandwiththeintentionofdefraudingpresentsfalseinformationinaninsuranceapplication,orpresents,helps,orcausesthepresentationofafraudulentclaimforthepaymentofalossoranyotherbenefit,orpresentsmorethanoneclaimforthesamedamageorloss,shallincurafelonyand,uponconviction,shallbesanctionedforeachviolationwiththepenaltyofafineofnotlessthanfivethousanddollars($5,000)andnotmorethantenthousanddollars($10,000),orafixedtermofimprisonmentforthree(3)years,orbothpenalties.Shouldaggravating circumstancesbepresent,thepenaltythus establishedmay beincreased toa maximum of five (5)years; ifextenuatingcircumstances are present, it maybe reduced toa minimum oftwo(2)years.

THEUNDERSIGNEDAUTHORIZEDREPRESENTATIVE(PRESIDENT,CEO,OROTHEROFFICERACCEPTABLETOTRAVELERS)OFTHEAPPLICANTDECLARESTHATTOTHEBESTOFHIS/HERKNOWLEDGEANDBELIEF,AFTERREASONABLEINQUIRY,THESTATEMENTSSETFORTHINTHEATTACHEDTRAVELERSNEWBUSINESSORRENEWALAPPLICATIONFORINSURANCEARETRUEANDCOMPLETEANDMAYBERELIEDUPONBYTRAVELERS.IFTHEINFORMATIONINANYAPPLICATIONCHANGESPRIORTOTHEINCEPTIONDATEOFTHEPOLICY,THEAPPLICANTWILLNOTIFYTHECOMPANYOFSUCHCHANGES,ANDTHECOMPANYMAYMODIFYORWITHDRAWANYOUTSTANDINGQUOTATION.THECOMPANYISAUTHORIZEDTOMAKE INQUIRY IN CONNECTIONWITHTHIS APPLICATION.

THESIGNINGOFTHISAPPLICATIONDOESNOTBINDTHECOMPANYTOOFFER,NORTHEAPPLICANTTOPURCHASE,THEINSURANCE.ITISAGREEDTHATTHISAPPLICATION,INCLUDINGANYMATERIALSUBMITTEDTHEREWITH,SHALLBETHEBASISOFTHEINSURANCEANDSHALLBE,INALLSTATESOTHERTHANNCANDUT,CONSIDEREDPHYSICALLYATTACHEDTOANDPARTOFTHEPOLICY,IFISSUED.THECOMPANYWILLHAVERELIEDUPONTHISAPPLICATION,INCLUDINGANYMATERIALSUBMITTEDTHEREWITH, IN ISSUING THE POLICY.

ELECTRONICALLY REPRODUCED SIGNATURESWILL BE TREATEDAS ORIGINAL.

Signature* of Applicant’s AuthorizedRepresentativeName(Printed)(President orCEO)

TitleDate

*IFYOUAREELECTRONICALLYSUBMITTINGTHISAPPLICATIONTOTRAVELERS,APPLYYOURELECTRONICSIGNATURETOTHISFORMBYCHECKINGTHEELECTRONICSIGNATUREANDACCEPTANCEBOXBELOW.BYDOINGSO,YOUHEREBYCONSENTANDAGREETHATYOURUSEOFAKEYPAD,MOUSE,OROTHERDEVICETOCHECKTHEELECTRONICSIGNATUREANDACCEPTANCEBOXCONSTITUTESYOURSIGNATURE,ACCEPTANCE,ANDAGREEMENTASIFACTUALLYSIGNEDBYYOUINWRITINGANDHASTHESAMEFORCEAND EFFECT ASA SIGNATURE AFFIXED BY HAND.

AUTHORIZED REPRESENTATIVE’SELECTRONICSIGNATURE ANDACCEPTANCE

Producer SignatureProducer Name (Printed)

Agency NameAgencyCodeLicense Number