Corporate Directors & Officers Liability and Employment Practices Liability Questionnaire- Brochure

CORPORATE DIRECTORS & OFFICERS LIABILITY ANDEMPLOYMENT PRACTICES LIABILITY QUESTIONNAIREALL QUESTIONS MUST BE ANSWERED AND APPLICATION MUST BE SIGNED BY APPLICANT.THIS IS AN APPLICATION FOR A CLAIMS MADE POLICY. PLEASE READ YOUR POLICY CAREFULLY.Defense Costs shall be applied against the retention. Please return this form by fax, mail, or email. 1a. Name of Organization:1b. E-mail:1c. Website (www.yourwebsite.com):1d. Mailing Address:1e. City, State, Zipcode:2a. Description of operations:2b. Date incorporated (mm/dd/yyyy):3. Are there any subsidiaries? Yes NoPlease provide for each: Name, Date Established; Location; Operations; Ownership; Assets; Employees.4. Name and Title of Officer designated to receive all notices on behalf of all Insureds:5. Current and Prior Insurance:Co. Exp. Premium Limits/RetentionD&OEPLE&OFiduciaryCrimeI n s u r a n c e a n d R i s k C o n t r o l S o l u t i o n s f o r E n v i r o n m e n t a l S e r v i c e F i r m sCA Lic# 0821383P. O. B o x 7 9 3 Te t o n Vi l l a g e W Y 8 3 0 2 5 8 0 0 . 7 4 6 . 0 0 4 8 t o l l f r e e 3 0 7 . 7 3 3 . 7 4 3 9 f a x w w w. v a n o p p e n c o 2 . c o mP.O. Box 793, Teton Village, WY 83025800.746.0048 toll free • 307.733.7439 fax • www.vanoppenco2.comInsurance and Risk Control Solutions for Environmental Service Firms1 of 86. Ownership6a-1) Number of shares outstanding - Voting: 6a-2) Number of shares outstanding - Non-Voting:6b-1) Number shareholders or members -Voting: 6b-2) Number shareholders or members - Non-Voting:6c) Number of shares/interests owned by the directors and officers (direct and beneficial):6d) Is the applicant a Subsidiary of another Organization? Yes NoName of Parent6e) Does any shareholder own 10% or more of the voting shares directly or beneficially? Yes No6f) Are there any other securities convertible to voting stock? Yes NoIf “yes,” please explain. 6g) Have any shares of the Organization been publicly traded within the last 3 years? Yes NoIf “yes,” please explain. 7. Management7a) Have there been any changes in the Board of Directors or Senior Management in the past 3 years for reasons other than expiration of term, death or retirement? Yes NoIf “yes,” please explain. 7b) Has the Organization changed outside auditors in the last 3 years? Yes NoIf “yes,” please explain. I n s u r a n c e a n d R i s k C o n t r o l S o l u t i o n s f o r E n v i r o n m e n t a l S e r v i c e F i r m sCA Lic# 0821383P. O. B o x 7 9 3 Te t o n Vi l l a g e W Y 8 3 0 2 5 8 0 0 . 7 4 6 . 0 0 4 8 t o l l f r e e 3 0 7 . 7 3 3 . 7 4 3 9 f a x w w w. v a n o p p e n c o 2 . c o mP.O. Box 793, Teton Village, WY 83025800.746.0048 toll free • 307.733.7439 fax • www.vanoppenco2.comInsurance and Risk Control Solutions for Environmental Service Firms2 of 87c) Have any auditors found any material weaknesses in Organization’s system of internal controls? Yes NoIf “yes,” please explain. 7d) Has the Organization violated or breached any debt covenant, loan agreement or other material obligation in the past 3 years? Yes NoIf “yes,” please explain. 8. Has the Organization in the past 36 months completed or agreed to, or does it contemplate within the next 12 months, any of the following, whether or not such transactions are or will be completed? 8a) Merger, acquisition or consolidation with another entity? Yes NoIf “yes,” please explain. 8b) Sale, distribution or divestiture of more than 25% of assets or stock of the Organization? Yes NoIf “yes,” please explain. 8c) Any registration for a public offering? Yes NoIf “yes,” please explain. 8d) Any private placement? Yes NoIf “yes,” please explain. 8e) Reorganization or formal arrangement with creditors? Yes NoI n s u r a n c e a n d R i s k C o n t r o l S o l u t i o n s f o r E n v i r o n m e n t a l S e r v i c e F i r m sCA Lic# 0821383P. O. B o x 7 9 3 Te t o n Vi l l a g e W Y 8 3 0 2 5 8 0 0 . 7 4 6 . 0 0 4 8 t o l l f r e e 3 0 7 . 7 3 3 . 7 4 3 9 f a x w w w. v a n o p p e n c o 2 . c o mP.O. Box 793, Teton Village, WY 83025800.746.0048 toll free • 307.733.7439 fax • www.vanoppenco2.comInsurance and Risk Control Solutions for Environmental Service Firms3 of 89. Total number of employees:Current 12 mo. Prior 12 mo. Anticipated next 12 mo.(if operating less than 5 years)Full TimePart TimeTemporary/SeasonalIndependent ContractorsLeased10. Is more than 20% of the Organization’s work force located in a state other than that shown in Item 1? Yes NoIf yes, please provide the number of workers at each location.11. Percentage of employees with total compensation including salaries, bonuses and commissions?$51,000 to $100,000 Over $100,00012a. Has the Organization closed any facilities, downsized, or otherwise reduced staff in the past 12 months? Yes No12b. Does the Organization anticipate doing so in the next 12 months? Yes NoIf “yes,” please explain. 13a. Number of employees involuntarily terminated or laid off in the past 12 months?13b. Number of employees involuntarily terminated or laid off in the past 24 months?14. Does the Organization have a human resources manager? Yes NoIf “No”, please advise who performs this function.I n s u r a n c e a n d R i s k C o n t r o l S o l u t i o n s f o r E n v i r o n m e n t a l S e r v i c e F i r m sCA Lic# 0821383P. O. B o x 7 9 3 Te t o n Vi l l a g e W Y 8 3 0 2 5 8 0 0 . 7 4 6 . 0 0 4 8 t o l l f r e e 3 0 7 . 7 3 3 . 7 4 3 9 f a x w w w. v a n o p p e n c o 2 . c o mP.O. Box 793, Teton Village, WY 83025800.746.0048 toll free • 307.733.7439 fax • www.vanoppenco2.comInsurance and Risk Control Solutions for Environmental Service Firms4 of 815a. Does the Organization have an Employment Handbook? Yes No15b. Does it include an “Employment at will” statement? Yes No16a. Does the Organization have a written Sexual Harassment Guideline? Yes No16b. Does it address harassment against third parties including customers, vendors and independent contractors? Yes No17a. Does the Organization have a written Anti-Discrimination (Equal Opportunity Employer) Guideline? Yes No17b. Does it address discrimination against third parties including customers, vendors and independent contractors? Yes No18. Does the Organization have a written Guideline or policy regarding use of E-mail, Internet and similar systems? Yes NoIf the answer to any of item #’s 15-18 is “Yes”, please attach copies of your Handbook and Guidelines. If the answer to any of item #’s 15-17 is “No”, please make sure you comply with item #23.19. Within the last 5 years has the Organization or any individual proposed for Insurance received any inquiry, complaint or notice of hearing from any Municipal, State or Federal Regulatory Authority or Congressional or Legislative Committee (including, but not limited to, Equal Employment Opportunity Commission (E.E.O.C.), and State Human Rights cases)? Yes NoIf “yes,” please explain. 20. Within the last 5 years, has any claim been made or is now pending, against the Organization, or any person proposed for Insurance in the capacity of Director, Officer, or Employee of the Organization? Yes NoIf “Yes,” attach details including: date; claimant; amounts of defense and indemnity payments/reserves; whether covered by insurance; remedial measures taken.21. Is any person or entity proposed for this Insurance aware of any fact, circumstance or situation which may result in a claim against the Organization or any of its Directors, Officers, or Employees? Yes NoIf “yes,” please explain. I n s u r a n c e a n d R i s k C o n t r o l S o l u t i o n s f o r E n v i r o n m e n t a l S e r v i c e F i r m sCA Lic# 0821383P. O. B o x 7 9 3 Te t o n Vi l l a g e W Y 8 3 0 2 5 8 0 0 . 7 4 6 . 0 0 4 8 t o l l f r e e 3 0 7 . 7 3 3 . 7 4 3 9 f a x w w w. v a n o p p e n c o 2 . c o mP.O. Box 793, Teton Village, WY 83025800.746.0048 toll free • 307.733.7439 fax • www.vanoppenco2.comInsurance and Risk Control Solutions for Environmental Service Firms5 of 822. Within the past 5 years, has any customer, vendor, independent contractor or other third party made a claim alleging sexual harassment or discrimination, is any such claim now pending against any entity or person proposed for this insurance or is any entity or person proposed for this insurance aware of any fact, circumstance or situation which may result in a claim of harassment or discrimination by a third party? Yes NoIf “yes,” please explain. 23. As President or Chairman of the Board of the applicant, I certify that the guidelines I have checked below have been implemented and distributed or will be implemented and distributed to each employee within 30 days of the effective date of the policy. United States Liability Insurance Group will attach an endorsement to the policy stating that failure to implement the guidelines I have checked below shall be grounds for denial of employment claims by the United States Liability Insurance Group. Sample guidelines are available upon request.All applicants must check each box for number 1 and 2 below certifying each has been or will be implemented as stated above.Anti-Sexual Harassment Policy (inclusive of the following): 1. Definition of Sexual Harassment, 2. Company will not tolerate this behavior, 3. Procedure for reporting and who to report it to, 4. Consequences of violating the policyAnti-Discrimination Policy (inclusive of the following): 1. Applies to employees and applicants for employment, 2. Identifies who a violation should be reported to, 3. Identifies each of the following classes: Race, Color, Creed, Age, Sex, National Origin, Disability, ReligionA check mark must be placed in each box for number 3 and 4 below certifying each has been or will be implemented as stated above only if a handbook is already in place or will be implemented by the applicant.“Employment at Will” (sample wording is available upon request) “Contract Disclaimer’ (sample wording is available upon request)I CERTIFY THAT THE STATEMENTS ABOVE ARE TRUE.Signature over printed name:Title:Date (mm/dd/yyyy):I n s u r a n c e a n d R i s k C o n t r o l S o l u t i o n s f o r E n v i r o n m e n t a l S e r v i c e F i r m sCA Lic# 0821383P. O. B o x 7 9 3 Te t o n Vi l l a g e W Y 8 3 0 2 5 8 0 0 . 7 4 6 . 0 0 4 8 t o l l f r e e 3 0 7 . 7 3 3 . 7 4 3 9 f a x w w w. v a n o p p e n c o 2 . c o mP.O. Box 793, Teton Village, WY 83025800.746.0048 toll free • 307.733.7439 fax • www.vanoppenco2.comInsurance and Risk Control Solutions for Environmental Service Firms6 of 8REQUIRED INFORMATION – Please send the following:A. Completed Application signed and dated by the President or Chairman of the Board and the Human Resource Manager (or individual responsible for the human resource function).B. Copy of the employment application.C. Most recent audited financial statement.D. Any registration statements filed with the SEC or any private placement memorandums within the last 12 months.E. List of Directors and OfficersThe undersigned represents that to the best of his/her knowledge and belief the particulars and statements set forth herein are true and agree that those particulars and statements are material to the acceptance of the risk assumed by the Company. The undersigned further declares that any claim, incident or event taking place prior to the effective date of the insurance applied for which may render inaccurate, untrue, or incomplete any statement made will immediately be reported in writing to the Company and the Company may withdraw or modify any outstanding quotations and/or authorization or agreement to bind the insurance. The Company is hereby authorized, but not required, to make any investigation and inquiry in connection with the information, statements and disclosures provided in this Application. The decision of the Company not to make or to limit any investigation or inquiry shall not be deemed a waiver of any rights by the Company and shall not stop the Company from relying on any statement in this Application. The signing of this Application does not bind the undersigned to purchase the insurance, nor does the review of this Application bind the Company to issue a policy. It is understood the Company is relying on this Application in the event the Policy is issued. It is agreed that this Application, including any material submitted therewith, shall be the basis of the contract should a policy be issued and it will be attached and become a part of the policy.ARIZONA AND OREGON FRAUD STATEMENT: 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 MAY BE SUBJECT TO A CIVIL PENALTY.PENNSYLVANIA FRAUD STATEMENT: 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 SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.UTAH, CONNECTICUT, OHIO FRAUD STATEMENT: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE/SHE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD.VIRGINIA FRAUD STATEMENT: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD AN INSURER, SUBMITS AN APPLICATION FOR INSURANCE OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD.FRAUD STATEMENT (ALL OTHER STATES): 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 FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR SUCH VIOLATION.IF THE PRIMARY ADDRESS OF THE LOCATION LISTED IN ITEM #1 IS IN THE STATE OF NEW YORK OR FLORIDA, THE STATES OF NEW YORK AND FLORIDA REQUIRE THAT WE HAVE THE NAMES AND ADDRESS OF YOUR (INSURED’S) AUTHORIZED AGENT OR BROKER.I n s u r a n c e a n d R i s k C o n t r o l S o l u t i o n s f o r E n v i r o n m e n t a l S e r v i c e F i r m sCA Lic# 0821383P. O. B o x 7 9 3 Te t o n Vi l l a g e W Y 8 3 0 2 5 8 0 0 . 7 4 6 . 0 0 4 8 t o l l f r e e 3 0 7 . 7 3 3 . 7 4 3 9 f a x w w w. v a n o p p e n c o 2 . c o mP.O. Box 793, Teton Village, WY 83025800.746.0048 toll free • 307.733.7439 fax • www.vanoppenco2.comInsurance and Risk Control Solutions for Environmental Service Firms7 of 8Name of authorized agent or broker:Mailing Address:City, State, Zipcode:Agent or broker license number:Name of Chairman of the Board or President:Name of Human Resource Manager or individual performing this function:I CERTIFY THAT THE STATEMENTS ABOVE ARE TRUE.Signature over printed name of person completing the questionnaire:Phone Number (ex: 000-000-0000): Date (mm/dd/yyyy):I n s u r a n c e a n d R i s k C o n t r o l S o l u t i o n s f o r E n v i r o n m e n t a l S e r v i c e F i r m sCA Lic# 0821383P. O. B o x 7 9 3 Te t o n Vi l l a g e W Y 8 3 0 2 5 8 0 0 . 7 4 6 . 0 0 4 8 t o l l f r e e 3 0 7 . 7 3 3 . 7 4 3 9 f a x w w w. v a n o p p e n c o 2 . c o mP.O. Box 793, Teton Village, WY 83025800.746.0048 toll free • 307.733.7439 fax • www.vanoppenco2.comInsurance and Risk Control Solutions for Environmental Service Firms8 of 8 1a Name of Organization: 1b Email: 1c Website wwwyourwebsitecom: 1d Mailing Address: 1e City State Zipcode: 2a Description of operations: 2b Date incorporated mmddyyyy: 3 Are there any subsidiaries: Please provide for each Name Date Established Location Operations Ownership Assets Employees: 4 Name and Title of Officer designated to receive all notices on behalf of all Insureds: CoDO: ExpDO: PremiumDO: LimitsRetentionDO: CoEPL: ExpEPL: PremiumEPL: LimitsRetentionEPL: CoEO: ExpEO: PremiumEO: LimitsRetentionEO: CoFiduciary: ExpFiduciary: PremiumFiduciary: LimitsRetentionFiduciary: CoCrime: ExpCrime: PremiumCrime: LimitsRetentionCrime: 6a1 Number of shares outstanding Voting: 6a2 Number of shares outstanding NonVoting: 6b1 Number shareholders or members Voting: 6b2 Number shareholders or members NonVoting: 6c Number of sharesinterests owned by the directors and officers direct and beneficial: 6d Is the applicant a Subsidiary of another Organization: Name of Parent: 6e Does any shareholder own 10 or more of the voting shares directly or beneficially: 6f Are there any other securities convertible to voting stock: If yes please explain: 6g Have any shares of the Organization been publicly traded within the last 3 years: If yes please explain_2: than expiration of term death or retirement: If yes please explain_3: 7b Has the Organization changed outside auditors in the last 3 years: If yes please explain_4: 7c Have any auditors found any material weaknesses in Organizations system of internal controls: If yes please explain_5: past 3 years: If yes please explain_6: 8a Merger acquisition or consolidation with another entity: If yes please explain_7: 8b Sale distribution or divestiture of more than 25 of assets or stock of the Organization: If yes please explain_8: 8c Any registration for a public offering: If yes please explain_9: 8d Any private placement: If yes please explain_10: 8e Reorganization or formal arrangement with creditors: Current 12 moFull Time: Prior 12 moFull Time: Anticipated next 12 mo if operating less than 5 yearsFull Time: Current 12 moPart Time: Prior 12 moPart Time: Anticipated next 12 mo if operating less than 5 yearsPart Time: Current 12 moTemporarySeasonal: Prior 12 moTemporarySeasonal: Anticipated next 12 mo if operating less than 5 yearsTemporarySeasonal: Current 12 moIndependent Contractors: Prior 12 moIndependent Contractors: Anticipated next 12 mo if operating less than 5 yearsIndependent Contractors: Current 12 moLeased: Prior 12 moLeased: Anticipated next 12 mo if operating less than 5 yearsLeased: 10: If yes please provide the number of workers at each location: 51000 to 100000: Over 100000: 12a: 12b: If yes please explain_11: 13a Number of employees involuntarily terminated or laid off in the past 12 months: 13b Number of employees involuntarily terminated or laid off in the past 24 months: 14: If No please advise who performs this function: 15a Does the Organization have an Employment Handbook: 15b Does it include an Employment at will statement: 16a Does the Organization have a written Sexual Harassment Guideline: 16b Does it address harassment against third parties including customers vendors and independent contractors: 17a Does the Organization have a written AntiDiscrimination Equal Opportunity Employer Guideline: 17b Does it address discrimination against third parties including customers vendors and independent contractors: 18 Does the Organization have a written Guideline or policy regarding use of Email Internet and similar systems: Rights cases: If yes please explain_12: proposed for Insurance in the capacity of Director Officer or Employee of the Organization: claim against the Organization or any of its Directors Officers or Employees: If yes please explain_13: result in a claim of harassment or discrimination by a third party: If yes please explain_14: Check Box4: Check Box5: Check Box6: Check Box7: Title: Date mmddyyyy: Name of authorized agent or broker: Mailing Address: City State Zipcode: Agent or broker license number: Name of Chairman of the Board or President: Name of Human Resource Manager or individual performing this function: Phone Number ex 0000000000: Date mmddyyyy_2: Clear Form: