DIRECTORS AND OFFICERS LIABILITY INSURANCE PROPOSAL FORM
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- Millicent Cobb
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1 DIRECTORS AND OFFICERS LIABILITY INSURANCE PROPOSAL FORM In completing the Proposal Form please ensure that questions are answered fully and accurately and where necessary schedules giving further explanation are provided. IMPORTANT NOTICE CONCERNING DISCLOSURE It is your duty to disclose all material facts to Underwriters. A material fact is one that is likely to influence an Underwriter s judgement and acceptance of your proposal. If your proposal is a renewal of an existing policy, it should also include any change in facts previously advised to Underwriters. If you are in any doubt as to whether or not facts are considered material, you should disclose them. Please te The following documents must be submitted with this proposal for:- (a) The audited accounts of the company for the last two (2) financial years; (b) The latest interim statement (if applicable); (c ) A copy of all circular letters sent to the company's shareholders during the past twelve (12) months; (d) The latest audited accounts of the ultimate Holding Company if applicable. 1. (a) Name of the Company: (b) Address of Head Office: Telephone.: / Fax.: address: (c ) If the Company stated in (a) is a subsidiary of another company, please state the name and address of the ultimate Holding Company:
2 2. (a) Type of company (e.g. Public, Private, Close, Mutual etc.) (b) Nature of business: (c ) Date since the company has continuously carried on business: 3. Name of each member of the Board of Directors of the Company: Name Date of appointment 4. Is cover required under this policy for Directors or Officers of the Company or of its subsidiary companies whilst holding positions in any associated company? IF YES, please provide in respect of each appointment the following:- Company in which Company of Activity Net Profit Net Worth position held Incorporation 5. (a) How many shareholders does the Company have? (b) Are there any shareholders who own 10% or more of the issued shares? 6. Is the Company:- (a) Listed on any Stock Exchange? If, please state which and date listing obtained: (b) Listed on the Unlisted Securties Market? Massy United Insurance Ltd. Page 2
3 6. Is the Company:- (c) Traded in any other way? If, please specify: 7. Please give:- Total Gross Assets. of Employees (a) The total gross assets of the Companies and its subsidiary companies and the number of employees in: (i) the United States of America: (ii) Canada: 8. In respect of any subsidiary company in the United States of America please advise: (a) The name of the subsidiary: (b) The company's percentage interest: (where not 100% owned please state who owns the minority stock): 9. Does the Company or any of its subsidiaries have any of their stocks, shares or debentures issued in the United States of America or Canada? If, please advise:- (a) On what date the last offer/tender/issue was made? (b) Was the offer subject to the United States Security Act 1933 and/or the Securities Exchange Act of 1934 and/or any amendments thereto? Massy United Insurance Ltd. Page 3
4 10. Please enclose a copy of the latest 20-F filing or similar filing made to the USA Regulatory Authorities: If not applicable please confirm. 11. Has the Company made any acquisitions or disposals during the past 18 months? If, please provide details: 12. Has the Company within past 18 months:- (i) Filed any registration statement for a public offering? (ii) Issued any shares (common or otherwise)? Is any such offering or share issue contemplated in the next 12 months? If, please provide details:- 13. (a) If Directors and Officers Liability Insurance has been carried during the past 3 years please state:- (i) The name of the Insurers: (ii) The period of the policy: (iii) The Indemnity Limit: (iv) The premium: (for the last policy issued) (b) As far as is known, have the Proposers ever been refused this type of insurance or had a similar insurance cancelled? If, please provide details: Massy United Insurance Ltd. Page 4
5 14. (a) If an insurance similar to that now proposed had been or were now in effect would any claim which has been made or which is now pending against any persons proposed for insurance have fallen within the scope of such insurance? If, please give details: (b) Is any person proposed for insurance aware, AFTER ENQUIRY, of any circumstances or incident which he/she has reason to suppose might afford grounds for any future claim such as would fall within the scope of the proposed insurance? If, please give details: 15. Amount of indemnity required: DECLARATION I, the undersigned, being a Director or Officer of the Company referred to in Item 1(a) of this proposal, hereby declare that:- 1. I am authorised to complete this proposal on behalf of the Company referred to in Item 1 of this proposal and all subsidiary companies declared herein; and 2. All answers to the questions contained in this proposal are, AFTER ENQUIRY, true and correct to the best of my knowledge and belief; and 3. I have read and understood the notes at the beginning of this proposal; and 4. I understood that the submission of this proposal does not bind either the Underwriters or the Company specified in Item 1 or any of the Subsidiary Companies declared herein, to enter into a binding contract of insurance. Signed Capacity Date... *It is important that the Company and all Subsidiary Companies declared herein, and the authorised Officer signing the Declaration above on their behalf, are fully aware of the scope of this insurance so that these questions can be answered correctly. If in doubt, please contact your broker since non-disclosure may effect an Assured's right of recovery under the policy or lead to voidance. Massy United Insurance Ltd. Page 5
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