NOT FOR PROFIT APPLICATION DIRECTORS AND OFFICERS, ENTITY AND PERSONAL LIABILITY INSURANCE

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1 NOT FOR PROFIT APPLICATION DIRECTORS AND OFFICERS, ENTITY AND PERSONAL LIABILITY INSURANCE 1. GENERAL INFORMATION This general information must be furnished with respect to each Entity and Plan to be named in Item 1 of the policy DECLARATIONS. a) Name: b) Address: Number Street City Province Postal Code Phone: Fax: Website: c) Please give a complete description of the Entity and Entity s (and Plan s if applicable) purpose and general operations including its legal structure: d) Date of Incorporation or constitution: Jurisdiction of Incorporation or constitution: Fiscal Year End: e) Territorial distribution of activities or services: Canada: % United States: % Elsewhere (please specify): % 2. FINANCIAL INFORMATION This financial information must be furnished with respect to each Entity and each Plan to be named in Item 1 of the policy DECLARATIONS. For the most recent fiscal year-end provide the following consolidated financial information: (a) Total Assets: $ (b) Total Liabilities: $ (c) Total Revenues: $ (d) Net Income: $ For the current fiscal year, please indicate: i) Estimated Revenue ii) Estimated surplus/deficit e) Please enumerate the major sources of income and the percentage of total income: 3. AMOUNT OF INSURANCE REQUESTED $ aggregate limit of liability each Policy Period. (actual amount to be provided will be indicated in the Policy DECLARATIONS in the event that a policy is issued); Please Note: Insuring Agreements (e) and (f) are generally subject to a maximum limit of $1,000,000. % % % 1

2 4. ENTITY/PLAN INFORMATION Item 1 of the Policy DECLARATIONS. a) If the Entity/Plan holds charitable status, has this status ever been revoked or subject to review? b) Is the Entity/Plan currently or has it, during the past twelve (12) months been in arrears in its payments of monies payable to Canada Customs and Revenue Agency or the provincial ministries or revenue (including source deductions, G.S.T, P.S.T and H.S.T)? c) Is the Entity/Plan currently or has it, at any time during the last three (3) years, been in breach of any of its debt covenants, loan agreements or contractual obligations, or does it anticipate any such breach occurring within the next twelve (12) months d) Has the Entity/Plan changed its outside accountant or external legal counsel during the past three (3) years? e) Has the Entity/Plan currently, or has it at any time during the last (3) years: (i) sought protection under the Companies Creditors Agreement Act (Canada), or (ii) made a proposal under the Bankruptcy and Insolvency Act, or (iii) sought protection under Chapter 11 of the U.S.C. (United States Bankruptcy Code), or does it anticipate seeking such protection or making such a proposal within the next twelve (12) months? (If the answer to any of the above is Yes, please provide full details.) 5. OPERATIONS Does the Entity/Plan or any person(s) proposed for this insurance: a) provide professional services (e.g. counseling services, referral services, legal aid services, or medical services) to its members or the public, whether or not a fee is charged? b) promote, sponsor or provide any form of insurance to its members or non-members? c) act as a licensing body or assess the qualifications of its members? d) take any disciplinary action or recommend disciplinary action as a result of peer review group activities? e) publish any written material, including without limitation magazines, periodicals, technical manuals, or blogs, whether on paper, on the internet or in any other form? 2

3 f) engage in broadcasting or reproduction of copyrighted material? g) engage in activities such as lobbying, labor negotiation or collective bargaining? (If the answer to any of the above questions is yes, please provide full details.) 6. BOARD PROCEDURES a) What is the usual rate of change / turnover in board members or trustees? b) How frequently does the Board of Directors or Trustees meet? c) How many board members or trustees must be present to constitute a quorum? d) Do the Directors or the Trustees see the meeting agenda and minutes from the board/trustee meetings at least ten days prior to each board/trustee meeting date? e) Does each Director or Trustee have a formal job description which clearly defines the Director s or Trustee s scope of duties? 7. OPERATIONAL PROCEDURES a) Do procedures exist to keep the Directors, Trustees and Committee members informed on operations, financial results and new developments? b) Have standard decision-making procedures been defined? c) Does a procedure for documenting majors decisions and events exist? d) Does a procedure for retention of essential legal, financial and personnel records exist? e) Are all Insured Persons, including Directors, Trustees and Committee members required to obtain legal counsel prior to publicly commenting on any of the Entity/Plan s activities? 8. EMPLOYMENT, MEMBERSHIP AND GOVERNANCE PRACTICES a) Number of Directors and Trustees located in: Canada: United States: Elsewhere (please specify): b) Number of Officers and Employees located in: Canada: United States: Elsewhere (please specify): 3

4 c) Number of Members located in: Canada: United States: Elsewhere (please specify): d) Number of Volunteers located in: Canada: United States: Elsewhere (please specify): e) Are any layoffs or staff reductions anticipated within the next two years? f) Does the Entity/Plan have the following in current use and practice: (i) (ii) written human resource policies, procedures and guidelines that have been vetted by a lawyer with expertise in employment law? formal training for its supervisors in administering these guidelines, policies and procedures? (iii) Authorization from an officer prior to terminating an Employee? 9. PENSION PLAN(S) Does the Entity sponsor a pension plan(s) other than a Plan to be named in Item 1 of the policy DECLARATIONS? If Yes, provide the name of the pension plan(s) and the following information: (i) Total plan assets (all plans combined): $ (ii) Number of plan(s) participants: (iii) Who manages the plan(s)? NOTE: with respect to item 9 above, notwithstanding the information submitted, and subject to the terms and conditions of the proposed insurance, coverage will only be afforded to Insured Persons with respect to those Plans to be named in 10. NOTICE Identify the Officer of the Entity/Plan designated to receive all notices from the Insurer concerning this insurance: NAME (please print) TITLE 4

5 11. PRIOR INSURANCE a) Have any Claims, Inquiries or Prosecutions, or facts or circumstances which might possibly give rise to a Claim, Inquiry or Prosecution, been reported to the current or any previous Directors and Officers Liability Insurance or Entity Errors & Omissions Liability Insurance or Fiduciary Liability Insurance Carrier? b) Have any claims, or facts or circumstances which might possibly give rise to a Claim, Inquiry or Prosecution NOT been reported to the current or any previous Directors and Officers Liability Insurance or Entity Errors & Omissions Liability Insurance or Fiduciary Liability Insurance carrier? (If the answer to either of the above questions is Yes, please provide full details on each.) c) Previous Directors and Officers Liability Insurance or Entity Errors & Omissions Liability Insurance or Fiduciary Liability Insurance (last 3 years): Name of Insurer Type of coverage Limit of Policy Retention s Period Premium Claims 12. WARRANTIES ALL PROPOSED INSUREDS AND (WHERE APPLICABLE) THE PLAN DO HEREBY PROVIDE THE FOLLOWING WARRANTIES TO THE INSURER: a) No Claim which would, had insurance similar to that now proposed been in force, have been covered under that insurance has been made or is not pending against any Proposed Insured, whether the Insured Persons or the Entity, except as follows: (If answer is none, please check here ) b) No Inquiry or Prosecution for which Legal Representation Costs would, had insurance similar to that proposed been in force, have been covered under that insurance, has Begun against or involving any Proposed Insured, except as follows: (If answer is none, please check here ) a) No fact, circumstance or situation indicating the possibility of a Claim which would be covered under the proposed insurance or a Prosecution or Inquiry with respect to which Legal Representation Costs would be covered under the proposed insurance is now known to any Proposed Insured or to any Plan, other than that which is disclosed in the Application, except as follows: (If answer is none, please check here ) d) No similar insurance sought or purchased by the Entity or in the Plan has been declined or cancelled or renewal thereof refused, except as follows: (If answer is none, please check here ) 5

6 e) Neither the Entity nor the Plan nor any of the Insured Persons has been involved in or has any knowledge of any currently pending insolvency and/or bankruptcy, anti-trust, combines, price fixing, restraint of trade, tax, copyright, patent, securities law or regulation infringement or government regulatory or administrative proceedings against the Entity, the Plan and/or the Insured Persons, except as follows: (If answer is none, please check here ) f) The undersigned director of the Entity is duly authorized to make representations and to sign on behalf of all of the Insured Persons and the Entity and the Plan and declares that the statements herein are true and complete. g) The undersigned director of the Entity declares that the financial statements submitted with this Application are representative of the current financial position of the Entity and the Plan. 13. AGREEMENT TO CONDITIONS BY SUBMITTING THIS APPLICATION, ALL PROPOSED INSUREDS AGREE TO AND ACCEPT THE FOLLOWING CONDITIONS: a) Any Claim, Inquiry or Prosecution contemplated by Question 12 a) or b) or resulting from, arising out of or in any way involving facts or circumstances or situations contemplated by Question 12 c) or proceedings contemplated by Question 12 e), will be excluded from coverage under the proposed insurance, whether or not it is disclosed in this Application. b) The signature and submission of this Application and any Application Information do not bind the Insurer to underwrite the proposed Policy. c) The Insurer is authorized to make an investigation and inquiry in connection with this Application and any Application Information that it may deem necessary. d) If the Insurer chooses to underwrite the proposed Policy, this application and any Application Information (which will be retained on file by the Insurer but which will be deemed attached hereto as if physically attached) will be the basis on which the Policy is underwritten, and will be attached to and become part of the insurance contract, subject to Policy terms and conditions. However, the terms and conditions of the proposed insurance will be defined exclusively by the wording of the Policy, if issued, and nothing in this Application constitutes an offer or representation as to the terms and conditions of coverage. e) In the event that there is any material change in the information contained in this Application or in the Application Information prior to the effective date of the Policy, the Entity will notify the Insurer and, at the sole discretion of the Insurer, any outstanding offer of terms and conditions or quotations may be modified or withdrawn. f) Coverage cannot be bound unless and until this original Application has been fully completed and duly signed, dated and delivered with any required Application Information to the Insurer. g) En soumettant la présente proposition en anglais les assurés proposés reconnaissent qu ils ont expressément demandé que la police, si elle est émise, ainsi que tout ou renouvellement futur, soient rédigés en anglais. In completing this Application in English, the Proposed Insureds hereby acknowledge that they have specifically requested that the Policy, if issued, as well as any endorsement thereto or renewal thereof, be drawn up in English. 6

7 PRIVACY DISCLOSURE AND CONSENT The undersigned authorized officer of the Entity acknowledges that any personal information provided in connection with the insurance applied for, including but not limited to the information contained in this Application and any Application Information, has been collected in accordance with all applicable privacy legislation. The undersigned confirms that all necessary consents have been obtained for the collection, use, and disclosure of such information for the purposes of any investigation any inquiry in connection with this Application for insurance and, if applicable, investigating and settling claims, detecting and preventing fraud, and acting as required or authorized by law. Entity (Print Block Letters) Letters) Name of Chairman of the Board or President (Print Block Date President Signature of Chairman of the Board or 7

8 APPENDIX A LIST OF DIRECTORS OR TRUSTEES AND OFFICERS (Please include titles of Proposed Insureds) DIRECTORS/TRUSTEES OFFICERS 8

9 APPENDIX B LIST OF COMMITTEES NAME OF COMMITTEE BRIEF DESCRIPTION OF FUNCTIONS 9

10 APPENDIX C SUBSIDIARIES OR AFFILIATED ENTITIES Does the Corporation have any Subsidiaries or Affiliated Entities for which coverage is required? If Yes, provide the following information: NAME NATURE OF OPERATIONS JURISDICTION OF INCORPATION NON-PROFIT ENTITY? 10

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