Proposal Forms

1. General Information

a. Company Name:

Address: (Only required if different to that for Senior Member on ITIC certificate)

E-mail:

Telephone:

Name of person to whom correspondence should be addressed:

b. Name and Address of any subsidiary companies to be insured for D&O including country of registration and percentage owned by parent company or organisation (information only required if different to those listed as Joint Members on your ITIC certificate of entry)

Name & address	Country	Percentage

c. Total number of Directors/Partners/Senior Managers:
Total number of staff:

d. Names, positions, professional qualifications and number of years’ experience of ALL current
Directors, Partners and Senior Managers (these names may already be listed in your company report and accounts)

Names of current Directors, Partners and Senior Managers	Qualifications	Year obtained	Length of time as Director, Partner or Principal

Please provide details if required.

2. Business activities

a. Please briefly describe the nature of your business (information only required if different to the insured services listed in paragraph 2.0 of your ITIC certificate of entry)

b. Please indicate your approximate gross annual income or fees and your profit for the years requested below.
Please state currency e.g., US$, EUR, GBP etc.

Gross income/fees for last year		Gross income estimate for this current financial year
Profit for last year		Estimated profit for this current financial year

c. Please provide copies of your company report and accounts and other relevant literature relating to your company or organisation such as brochures, annual reviews etc. † † † †

d. Are any of the companies declared above listed on any stock exchange or traded? yes no

If “Yes” please identify them and specify country and city and specify how traded.

e. Are any of the companies declared above regulated by any professional body? yes no

If “Yes” please identify them and specify which regulatory body oversees their function.

f. Please list any “associated company” (which is not a subsidiary) in which any of your Directors, Partners or Senior Managers are required by your company to perform a similar role, and give the location and a description of the business activity of this organisation.

Associated company name	Location	Business activity

Please provide details if required.

3. Directors’ & Officers’ Insurance/Claims

a. Are you currently insured for Directors’ and Officers’ liability insurance risks? yes no

If “Yes” how long have you been insured?. (If “No” please give details of most recent insurance)

Please state currency e.g., US$, EUR, GBP etc.

Name of insurer?		Limit of indemnity?
Excess/Deductible		Premium
Expiry date

b. Has any insurer

Declined to insure you	yes no	Cancelled your insurance	yes no
Refused to renew your insurance	yes no	Imposed penalties or special terms	yes no

If “Yes” please give details.

c. Have any claims, successful or not, ever been made against any past or present Director, Officer or Senior Manager of the company, or any subsidiary, that would fall within a similar insurance, or has the company or its Directors’ or Officers’ been subject to any regulatory enquiry within the last 6 years? yes no

If “Yes” please give details.

d. Are you aware after enquiry of any circumstance or incident that may give rise to a claim under a Directors’ and Officers’ liability insurance policy? yes no

If “Yes” please give details.

4. Limits and Deductibles:

Please indicate any preferred limits or deductibles:

Alternative 1

Limit

Deductible

Please state currency

Alternative 2

Limit

Deductible

Please state currency

I/We undertake that if this proposal is accepted I/We will act and abide and agree to be bound by the Rules of ITIC and any modification or alteration thereof made in accordance therewith from time to time by the decision of the Club and its Directors. I/We declare that to the best of my/our knowledge and belief, the information given above is true and that I/We have not suppressed or misstated any material facts. (A material fact is one likely to influence the underwriter’s assessment of this proposal).

Name:

Status:

Date:

† The total aggregate size of all your attached files should not exceed 10Mb.

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Directors' & Officers' Proposal Form

1. General Information

2. Business activities

3. Directors’ & Officers’ Insurance/Claims

4. Limits and Deductibles:

Alternative 1

Alternative 2