Directors & Officers Application

The following information is required to submit a Directors & Officers Application. All information must be completed. Should you require assistance to complete this form, please contact your service representative.

Insured Information

  1. Check Coverage Desired Section Requested Limit Requested Retention
    2 $ $
    3 $ $



  2. Financial Information Current Fiscal Year Previous Fiscal Year
    Total Assets:
    Net Assets / Fund Balance:
    Annual Revenue:
    Net Revenue:

  3. Please provide the following employee count information:







    0

  4. How many employees have been terminated or demoted in the past twelve (12) months?




  5. Is any reduction of employees or change of status anticipated in the next year?




  6. Does the Applicant have an employment handbook?



    Does the Applicant use an employment application for every potential employee?



    Does the Applicant have an "At Will" provision in the employment application or handbook?



    Has the Applicant implemented an anti-sexual harrasment policy?



    Has the Applicant implemented an anti-discrimination policy?



    Does the Applicant use outside employment counsel for employment advice?

General Summary
  1. Has the Applicant given written notice under the provisions of any prior policies providing similar insurance or claims, or of specific facts or circumstances which might give rise to a claim being made against any person or entity applying for this insurance? (If yes, complete a Claim Supplemental for each incident.)


  2. No person applying for this coverage is aware of any facts or circumstance which he or she has reason to suppose might give rise to a future claim that would fall within the scope of any of the proposed coverages for which the Applicant has applied, except (select None, or fill in the box with exceptions):


Submission
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  • You may also print and fax this form for processing to: (718) 389-4300