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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
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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.
Location
Mailing Address Only
P.O. Box 868
Oakhurst, NJ 07755
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