DIRECTORS AND OFFICERS PROPOSTA DI POLIZZA
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1 DIRECTORS AND OFFICERS PROPOSTA DI POLIZZA La presente proposta deve essere compilata dall`amministratore o dal Sindaco della Societa` proponente dotato di opportuni poteri. La firma della presente proposta non comparta alcun obbligo per l`assicuratore ne` comporta alcuna copertura assicurativa. This proposal form must be completed by a director or company secretary, and answered fully for a quotation to be given. The completion and signature of this proposal form does not bind the Company or Insurer to complete a contract of insurance. If necessary, additional information should be provided on the Company s letter headed paper. Se necessario potete integrare le informazioni su carta intestata del Proponente. 1. Name of Company/me del proponente 2. Registered address/indirizzo della sede legale 3. Year of establishment / Data Fondazione 4. Legal status of Company / Tipo di societa` Privately Owned (capitale riferibile a soggetti privati ) Publicly Owned (capitale riferibile a soggetti pubblici ) Charity or t-for- Profit ( organizzazioni no- profit o caritatevoli ) 5. Nature of business/tipo di attivita` IWFP210 Page 1 of 5
2 6. Number of shareholders of the Company /Numero dei soci 7. Percentage of shares held by directors of the Company/ percentuale di quote detenuta dagli amministratori 8. Full details of shareholders who own 10% or more of issued shares / Dettagli di tutti i soci con piu` del 10% di quote 0 azioni Shareholders - Azionista Percentage Owned Percentuale posseduta 9. Is the Company listed on any Stock Exchange?La societa` e` quotata? 10. Is the Company contemplating any offering or share issue in the next 12 months?la societa` ha emesso azioni negli ultimi 12 mesi? 11. Does the Company have any acquisition, tender offer or merger pending or under consideration?la societa` ha in corso o sta considerando alcuna fusione, acquisizione IWFP210 Page 2 of 5
3 12. Is the Company aware of any proposal relating to its acquisition by another organisation? La Societa` e` al corrente di intenzioni di acquisizione da parte di alter organizzazioni? 13. Have there been any acquisitions, disposals or created subsidiaries in the past 12 months? Ci sono state acquisizioni o creazioni di societa` collegate negli ultimi 12 mesi? 14. During the past five years, has either the capital structure or the name of the Company changed?negli ultimi 5 anni la struttura societaria o il nome della societa` sono cambiati? IWFP210 Page 3 of 5
4 15. If this proposal is not for a renewal by W. R. Berkley Insurance (Europe), Ltd, does the Company currently have Directors & Officers Liability in force? Nel caso in cui questa proposta non sia riferita ad un rinnovo con W.R. Berkley Esiste al momento copertura assicurativa D&O? If so, please confirm: Se si confermare : Insurer - Compagnia Limit of Indemnity - Massimali Policy Period Periodo Assicurativo Premium - Premio 16. Has the Company ever been refused this type of insurance or had a similar insurance cancelled? Il proponente ha mai avuto una polizza D&O cancellata o rifiutata? 17. Have any claims ever been made against any past or present director, officer or employee of the Company or its subsidiaries? Il proponente ha mai avuto richieste di risarcimento danni dirette ad uno degli amministratori dirigenti o dipendenti della società? 18. Is the Company or any director, officer or employee aware, after enquiry, of any circumstance or incident that may give rise to a claim? E` il Proponente o alcuno dei suoi dipendenti a conoscenza di qualsiasi circostanza che potrebbe dare origine ad un sinistro o richiesta di risarcimento danni? IWFP210 Page 4 of 5
5 Please complete questions if cover is required for activities in rth America Da completare solo in caso di estensione a rd America 19. What is the total gross assets of the Company and its subsidiaries in rth America? Quale e` il valore delle attivita` della societa` incluso le collegate in rd America? 20. What is the total turnover of the Company and its subsidiaries derived from rth America? Quale e` il giro di affari totale delle sedi in rd America? 21. Does the Company or any of its subsidiaries have any shares traded in the United States of America? Il proponente ha azioni scambiate in una borsa negli Stati Uniti? If so, please state the percentage of total shares traded, and enclose a copy of the latest 20-F filing or similar filing made to the USA Regulatory Authorities. Se si indicate il valore totale ed il numero delle azioni scambiate : 22. Does the Company have any shares traded in the form of ADRs? La Compagnia ha azioni scambiate in forma di ADR? DECLARATION I/We declare that the contents of this proposal form are true and that I/we have not mis-stated or suppressed any material facts. I/We agree that this proposal form together with any other information supplied by me/us shall form the basis of any contract of insurance effected hereon. I/We undertake to inform Insurers of any material alteration to these facts occurring before completion of the contract of insurance. Dichiaro che tutto quanto qui riportato corrisponde a verita` e che il rischio eventualmente assunto dall`assicuratore lo e` sulla base di queste informazioni da me rilasciate.se tali informazioni cambiano ho il dovere di informare l`assicuratore prima della sottoscrizione del contratto assicurativo. Please attach a copy of the most recent audited annual accounts for the Company and the latest interim statement (if applicable). In allegato copia dei piu` recenti bilanci. Signed/ Firma Capacity / Posizione Company / Società Date IWFP210 Page 5 of 5
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