Applicant's Name

Agency Name

Address

Agent

Address

Location

Email

Web Site Address

Phone

NOTICE:  EXCEPT AS OTHERWISE SPECIFICALLY PROVIDED HEREIN, COVERAGE PROVIDED UNDER THIS POLICY IS LIMITED TO LIABILITY FOR ONLY THOSE CLAIMS WHICH ARE FIRST MADE AGAINST THE INSURED AND REPORTED TO THE INSURER DURING THE POLICY PERIOD OR ANY RENEWAL THEREOF OR THE DISCOVERY PERIOD (IF APPLICABLE).

NOTICE:  THE LIMIT OF LIABILITY SHALL BE REDUCED BY AMOUNTS INCURRED FOR DEFENSE COSTS.  AMOUNTS PAID AS DEFENSE COSTS SHALL BE APPLIED AGAINST THE RETENTION AMOUNT.

NOTICE:  THE INSURER DOES NOT ASSUME ANY DUTY TO DEFEND; HOWEVER, THE INSURER MAY, AND IN CERTAIN CIRCUMSTANCES MUST, ADVANCE DEFENSE COSTS PAYMENTS PRIOR TO THE FINAL DISPOSITION OF A CLAIM.

1.

Name of Company:

Address:

2.

State of Incorporation

3.

Date from which the Company has continuously operated:

4.

Nature of Operations:

5.

Stock Ownership:

(a)

Number of common shares outstanding

(b)

Number of common stock shareholders

(c)

Number of common shares owned (directly

and beneficially) by directors

(d)

Number of common shares owned (directly and

beneficially) by officers who are not directors

(e)

Does any shareholder own directly or beneficially

10% or more of the common shares?

No Yes

(If so, give details)

6.

Subsidiary Companies:

  Name of Subsidiary

Type of Operation

% Owned

Date Acquired/Created

7.

Complete list of all Directors and Officers of the Company and its Subsidiary Companies by name and Affiliations with other Corporations.

8.

The Officer of the Company designated to receive any and all notices from the Insurers concerning this insurance:

9.

Has the Company:

(a)

Under consideration at the present time or does it contemplate any mergers, acquisitions or consolidations?

(b)

Filed or contemplated filing any registration statement with the Securities and Exchange Commission within the past

eighteen (18) months or within the next twelve (12) months for a public offering or securities?

10.

Has the Corporation, its Directors and/or Officers been involved in any of the following:

(a)

Any anit-trust, copyright or patent litigation?

(b)

Any criminal or civil action or administrative proceeding charging a violation of any federal or state security law or regulation?

(c)

Any representative actions, class actions or derivative suits?

(d)

Any criminal or civil action or administrative proceeding charging a violation of any federal or state anti-trust or Fair Trade Law?

11.

It is agreed with respect to facts or circumstances which may exist with respect to Question #10 that any claim or action

arising therefrom is excluded from this proposed coverage.

12.

Is any Director or Officer proposed for insurance aware of any act, error or omission involving the Company, its subsidiaries

or the Directors of Officers of the Company or its Subsidiaries which might give rise to a claim under the proposed policy?

13.

If insurance had been or were now in force similar to that now proposed, would any claim within the scope of such insurance

have been made or is such now pending against any person proposed to insurance in his capacity of either Director or Officer

of the Company or any other coporation?

14.

Previous Directors and Officers Liability insurance:

(a)

Company

(b)

Limit

(c) Self-Insured Retention

(d)

Premium (indicate annual or three year)

(e)

Policy Term

15.

Has any carrier refused or canceled coverage? (If canceled, date of cancellation)

16.

Amount of indemnity required $

17.

It is agreed that the Directors and Officers shall give the Insurer the right to associate with them in the defense and settlement of

any claim that appears reasonably likely to involve the Insurer and the Directors and Officers will cooperate with the Insurer in

the defense of such claim.

18.

NO FACT, CIRCUMSTANCE OR SITUATION INDICATING THE PROBABILITY OF A CLAIM OR ACTION

AGAINST WHICH INDEMNIFICATION IS OR WOULD BE AFFORDED BY THE PROPOSED INSURANCE IS

NOW KNOW TO ANY DIRECTOR, OFFICER, TRUSTEE, EMPLOYEE OR VOLUNTEER OF THIS ORGANIZATION,

AND IT IS AGREED BY ALL CONCERNED THAT IF THERE BE KNOWLEDGE OF ANY SUCH FACT,

CIRCUMSTANCE OR SITUATION, ANY CLAIM OR ACTION SUBSEQUENTLY EMANATING THEREFROM

SHALL BE EXCLUDED FROM COVERAGE UNDER THE PROPOSED INSURANCE.

19.

 Attached and made a part of this Application by reference is one copy of each of the following:

 (a)

The latest audited Annual Report (including balance sheet and income statement),

 (b)

If available, latest 10-K and 10-Q reports filed with the S.E.C.,

 (c)

The latest interim financial statement

 (d)

A copy of the indemnification provisions of the by-laws, and

 (e)

Schedule of Directors, Trustees, and Officers.

20.

The undersigned authorized Officer of the organization on behalf of the applicant and all persons or concerns seeking

insurance, has read and understands the Application and declares that all statements set forth herein are true, complete

and accurate.  The undersigned further declares and represents that any occurrence or event taking place prior to the

issuance of the policy applied for, which may render inaccurate, untrue or incomplete any statement made herein will

immediately be reported in writing to the Insurer.  The undersigned acknowledges and agrees that the submission and

the Insurer's receipt of such written report, prior to the inception of the policy applied for, is a condition precedent to

coverage.

NOTICE TO NEW YORK APPLICANTS:  ANY PERSON WHO KNOWINGLY AND WITH INTENT TO

DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR

INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION,

OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT

MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND

SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED $5,000 AND THE STATED

VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.

Although the signing of this Application does not bind the undersigned on behalf of the Directors and Officers and the Organization to effect insurance, the undersigned, on behalf of the Directors and Officers and the organization, agrees that this Application and the information furnished pursuant hereto shall be the basis of the contract should a policy be issued and this Application will be attached to and become part of the policy.  The Insurers are hereby authorized to make any investigation and inquiry in connection with this Application as they may deem necessary.

Must be Signed by Chairman of the Board or President

2.  Hit this Submit button.