Directors & Officers Online Application

Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Personal Information

First Name

Required

Last Name

Required

Formal Name of Business

Required

Is this a non-profit organization?

Required

Business Type

Required

Street

Required

City

Required

State

Required

ZIP / Postal Code

Required

Primary Phone Number

Required

E-Mail Address

Required

Website Address:

Required

Does the applicant want any subsidiaries covered?

Optional

If yes, provide name of company, % owned by applicant, address and description of operations.

Optional

Is the applicant a subsidiary of another organization?

Required

Name of parent and address:

Optional

FINANCIAL INFORMATION

Total Current Assets

Optional

Total Current Liabilities

Optional

Total Debt

Optional

Current 12 month annual gross revenues

Optional

Total annual income or (loss)

Optional

EMPLOYEE COUNT

Full-time employees

Required

Part-time

Required

Temporary/Seasonal

Required

Independent Contractors

Required

Leased employees

Required

How many of the above are located in California?

Required

How many of the above are located in Florida?

Required

How many of the above are located in Louisiana?

Required

How many of the above are located outside the USA?

Required

DIRECTORS AND OFFICERS SECTION

Please list all shareholders by name that own greater than 10%, with % owned and advise if they are a Director or Officer..

Optional

Have there been any changes in the board of directors or senior management in the past three years for reason other than expiration of term, death or retirement?

Required

Has the applicant changed outside auditors in the last three years?

Required

Have the auditors found any material weaknesses in applicants system of internal controls?

Required

Has the applicant violated or breached any debt covenant, loan agreement or other material obligation in the past three years?

Required

Has the applicant, in the past 36 months, completed or agreed to a merger, acquisition or consolidation with another entity?

Required

Has the applicant, in the past 36 months, completed or agreed to a sale, distribution or divestiture of more than 25% of assets of stock of the organization?

Required

Has the applicant, in the past 36 months, completed or agreed to any registration for a public offering?

Required

Has the applicant, in the past 36 months, completed or agreed to any private placement?

Required

Has the applicant, in the past 36 months, completed or agreed to any reorganization or formal arrangement with creditors?

Required

Has the applicant or any person proposed for coverage (whether or not in the service of applicant) been the subject of or been involved directly or indirectly in any civil, criminal, regulatory, legislative or administrative proceeding(s)?

Required

EMPLOYMENT PRACTICES LIABILITY SECTION

Do more than 50% of all employees currently earn more than $100,000?

Required

Has any entity proposed for insurance downsized, laid off, or reduced staff in the past 12 months or anticipate doing so in the next 12 months?

Required

If “Yes,” what percentage of the workforce was/will be affected?

Optional

WRITTEN GUIDELINES REQUIREMENTS

Does each entity proposed for insurance have a written email/internet policy currently in place or is willing to implement one within 21 days of binding

Required

Does each entity proposed for insurance have a written anti-discrimination and anti-harassment policy currently in place?

Required

Plans offered by applicant:

Required

Hold down the Ctrl Key to make multiple selections.

If a plan is offered, provide name of plan, type of plan, what are the current plan assets and # of participants.

Optional

If a 401k plan is offered, does each 401K plan allow the participants to select from at least three investment options and to monitor the performance of each selection?

Optional

Are 401k participants advised of the performance of their investment options and given the opportunity to adjust their selections at least annually?

Required

Does each plan subject to ERISA (Employee Retirement Income Security Act) comply with all applicable requirements of ERISA and the Internal Revenue Code of 1986, as amended (the “Code”) including eligibility, participation, vesting, fiduciary standards?

Optional

Has each plan been reviewed to ensure that there are no violations of any plan document or of the ERISA and “Code” prohibited transactions?

Required

Within the past 18 months, has an actuary found that any plan was or is currently under-funded by more than 10%?

Required

LOSS INFORMATION

Within the last five years has any employment related, third party harassment or third party discrimination claim, suit, inquiry, complaint or notice of hearing been made against the applicant or any individual proposed for insurance?

Required

Within the last five years, has any claim, suit inquiry, complaint or notice of hearing been made against the applicant or any person proposed for Insurance in the capacity of director, officer, or employee of the applicant?

Required

Is any person or entity proposed for this Insurance aware of any fact, circumstance or situation which may result in a claim against the applicant or any of its directors, officers or employees?

Required

If yes, please explain:

Optional

Within the past five years, has any claim been made or is any claim now pending against any plan, organization or individual proposed for this insurance in the capacity as a fiduciary, trustee or administrator?

Required

If yes, please explain:

Optional

Is any person or entity proposed for this insurance aware of any fact, circumstance, situation or ERISA violation which may result in a claim that may fall within the scope of the proposed Insurance?

Required

If yes, please explain:

Optional

How did you hear about us?

Optional

Additional Comments

Optional

Submission Validation

Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

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P.O. Box 868
Oakhurst, NJ 07755