APPLICATION FORM for DIRECTORS AND OFFICERS LIABILITY INSURANCE
If a Policy is issued, it will be on a CLAIMS-MADE basis.
The APPLICATION should be submitted along with the last two ANNUAL REPORTS and FINANCIAL (PROFIT AND LOSS) STATEMENTS of the company.
NOTICE: This application is confidential and signing this form does not bind the applicant to complete this insurance.
1. a) Name and address of the company:
b) Names and positions of Directors and Officers to be insured:
c) Number, place and date of registration of the company:
2. Form of the company (Rt, Kft, Bt, etc.):
3. How long has the company continually carried on business:
4. Business activities of the company and its subsidiaries:
5. a) Total number of shares issued:
b) Total number of shareholders:
c) Total number of shares held by directors and officers (both direct and beneficial):
d) Number of shares issued by type (series, preferred, restricted, etc.):
6. Is the company - or one of its subsidiaries - listed on a stock exchange? Yes No
If yes, please specify: a) Where: b) Since when: c) Share value: d) Total number of shares traded on the stock exchange:
7. Please list the shareholders owing more than 5 % of the shares of the company:
Name % of shared held
1 8. Complete list of the local and foreign subsidiaries and sub-subsidiaries with the percentage held directly or indirectly, also indicate it if you want it/them to be covered under your policy:
Name % of shared held Coverage Yes / No
9. Has the company made any acquisition(s) or merger(s) during the past year? Yes No
If yes, please give details:
10. Has the company any acquisition(s) or merger(s) pending or under consideration? Yes No
If yes, please give details:
11. Has this intention been presented for approval by the shareholders? Yes No
12. Is the company aware of any proposal relating to its acquisition by another company? Yes No
13. Has the company modified its capital structure in the past two years or does the company have any intention of modifying its capital structure in the future? Yes No
If yes, please give details:
14. Has the company already had directors and officers liability insurance? Yes No
If yes, please give details:
a) Name of the insurer:
b) Date and reasons for cancellation:
c) Number and amounts of claims:
15. Please give complete list of all subsidiary companies including country of registration and percentage owned by parent company other than as shown in the last report and accounts and:
Subsidiary companies Country of registration Covere % owned by parent d or company not?
2 16. Please give details of any change to the list of all directors and officers given in the company's last report and accounts:
17. Have claims ever been made against any past or present director or officer of the company or its subsidiaries? Yes No
If yes, please give details:
18. Is the Proposer aware, after inquiry, of any circumstance or incident which may give rise to a claim? Yes No
If yes, please give details:
19. AMOUNT OF INDEMNITY required? ...... HUF if coverage is required in respect of claims made in the United States of America or Canada or claims made elsewhere arising out of the company's operations in the United States of America or Canada, should you ask for a proposal form that includes questions relating to USA/Canada risk.
IMPORTANT!
THE UNDERSIGNED AUTHORIZED OFFICER OF THE APPLICANT DECLARES THAT THE STATEMENTS SET FORTH HEREIN ARE TRUE. THE UNDERSIGNED AUTHORIZED OFFICER AGREES THAT IF THE INFORMATION SUPPLIED ON THIS APPLICATION CHANGES BETWEEN THE DATE OF THIS APPLICATION AND THE EFFECTIVE DATE OF THE INSURANCE, HE/SHE (UNDERSIGNED) WILL IMMEDIATELY NOTIFY THE INSURER OF SUCH CHANGES, AND THE INSURER MAY WITHDRAW OR MODIFY ANY OUTSTANDING QUOTATIONS AND/OR AUTHORIZATION OR AGREEMENT TO BIND THE INSURANCE.
SIGNING OF THIS APPLICATION DOES NOT BIND THE APPLICANT NOR THE INSURER TO COMPLETE THE INSURANCE, BUT IT IS AGREED THAT THIS FORM SHALL BE THE BASIS OF THE CONTRACT SHOULD A POLICY BE ISSUED, AND IT WILL BE ATTACHED TO AND BECOME A PART OF THE POLICY.
ALL WRITTEN STATEMENTS AND MATERIALS FURNISHED TO THE INSURER IN CONJUNCTION WITH THIS APPLICATION ARE HEREBY INCORPORATED BY REFERENCE INTO THIS APPLICATION AND MADE A PART THEREOF.
Signed by:
Title (Chairman or Chief Executive):
Date:
Corporation: (Corporate Seal)
3