Executive First® Private Company Portfolio...Page 3 of 14 | Executive First Private Company...
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Page1of14|ExecutiveFirstPrivateCompanyPortfolioApplication12/2015
Executive First® Private Company Portfolio Application
NOTICE: THECOMPLETIONOFTHISAPPLICATIONDOESNOTBINDTHE INSURERTOOFFER,NORTHEAPPLICANTTOPURCHASEINSURANCE. THE INSURERWILL RELY UPON THE ACCURACY AND COMPLETENESS OF THIS APPLICATION FOR INSURANCE, INADDITIONTOINFORMATIONSUPPLIEDVIAATTACHMENT,ANDINPUBLICFILINGS.THISAPPLICATIONWILLFORMTHEBASISOF,ANDBECOMEPARTOF,ANYRESULTINGPOLICY. COVERAGEUNDERANYSUCHPOLICYWILLBEONACLAIMS-MADEBASIS. NOCOVERAGEWILLEXISTFORCLAIMSFIRSTMADEAGAINSTANINSUREDAFTERTHEENDOFTHEPOLICYPERIODUNLESSANDTOTHEEXTENTTHATANEXTENDEDREPORTINGPERIODAPPLIES. DEFENSECOSTSWILLREDUCEANDMAYEXHAUSTTHELIMITOFLIABILITYUNDERSUCHPOLICY,ANDWILLALSOBEAPPLIEDAGAINSTTHERETENTION.Instructions: Applicantshouldcompletethesectionsof theApplicationrelevant to thespecificcoveragesrequested. Theterm“Applicant”shallmeantheParentOrganizationapplyingforthisinsuranceandallofitsSubsidiaries.
I.GeneralInformation
1.NameofApplicant:
AddressofApplicant:
Street:______________________________________________________________________________________________City:______________________________________________State:____________________________Zip________________
2.NatureofOperationsandPrimarySICCode:
3.ArethereanySubsidiarieswithoperationsthataredissimilartowhatislistedabove?
Ifso,pleasedescribe.
Yes No
______________________________________________________
4.ApplicantWebSite(s):
5.YearsofContinuousOperation:
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6.IstheApplicantpublicly-heldorapublicreportingcompanyundertheSecuritiesExchangeActof1934asamended?
Yes No
7.a.HastheApplicantinthelast12monthscompletedany:i)Merger,acquisitionordivestment?ii)Restructuring,reorganizationorarrangementwithcreditors?iii)Bankruptcyfiling?
Yes NoYes NoYes No
b.IstheApplicantanticipatinganyoftheeventsshownin7.a.aboveinthenext12months?
Yes No
Ifanyquestionaboveis“Yes,”pleaseattachdetails.
II.Applicant’sFinancialInformation:PleasecompletethebelowgridfortheApplicant’smostrecentfiscalyearending______________Month_______________Year
TotalRevenues
$
NetIncomeor NetLoss
$
CashflowfromOperatingActivitiesPositive Negative
$
CurrentAssets
$
TotalAssets
$
CurrentLiabilities
$
LongTermDebt
$
TotalLiabilities
$
RetainedEarningsPositive Negative
$
Shareholder’sEquityPositive Negative
$
8.Willmorethan50%ofthetotallong-termliabilitiesmaturewithinthenext18months?If“Yes,”pleaseprovidedetailsbyattachment. Yes No
PleaseprovidetheApplicant’smostrecentannualfinancialstatements(auditedifavailable).
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III.InsuranceInformation:Pleaseplacean“X”intheboxbelowforeachcoveragerequested.“ContinuityDate”meansthepolicyinceptiondateforwhichamainformapplicationwasmostrecentlycompletedandcoveragecontinuallymaintained.Ifthereisnocurrentcoverage,pleaserespond“N/A”inthe“LimitCurrentlyPurchased”field. CoverageRequested LimitRequested Limit
CurrentlyPurchased
RetentionCurrentlyPurchased
ContinuityDate
CurrentInsurer
DirectorsandOfficersLiability
EmploymentPracticesLiability
FiduciaryLiability
EmployedLawyersLiability
Crime
* *
*IfcurrentCrimeprogramhasvaryinglimitsandretentions,pleaseprovidedetailsbyattachment.
9.Hasanypriorinsurermadeanypayments,beensentnoticeofaclaimorpotentialclaim,ornon-renewedanymanagementliability,crimeorsimilarinsuranceanytimeinthepast24months?If“Yes,”pleaseprovidedetailsbyattachment.
Yes No
FullycompletetheCoverageSectionQuestionsforeachcoveragethatisbeingrequested.
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DirectorsandOfficersLiabilityCoverageSectionQuestionsPlease answer the following questions if Directors and Officers Liability coverage is being requested
Ownership
1.PercentofoutstandingvotingsharesorvotingrightsoftheApplicantownedby,directlyorindirectly,theDirectorsandOfficersoftheApplicant
%
2.Listanyshareholdersthatownorcontrolmorethan5%oftheApplicantthatarenotDirectorsorOfficersoftheApplicant(useadditionalsheets,ifnecessary):
VotingShares
Owned/Controlled
%
%
%
%
3.Totalnumberofvotingshareholders
Transactions&Operations4.Withinthelast18months,hastheApplicanthadorattempteda:a)Publicorprivateofferingofdebtorequitysecurities,includinganyofferingunder
theJumpstartOurBusinessStartupsAct(JOBSAct)?b)Changeindirectorsorseniorofficers?
Yes No
Yes No
5.Withinthenext18months,doestheApplicantanticipateany:
a) PublicorprivateofferingofequitysecuritiesincludinganyofferingundertheJumpstartOurBusinessStartupsAct(JOBSAct)?
b) Publicorprivateofferingofdebt?c) Saleofsecurities,services,goodsorproductsforthepurposeoffundingApplicant
operationsorcapitalthroughsocialnetworking,crowdfunding,crowdsourcingorsimilarmethod?
Yes No
Yes No Yes No
6.HastheApplicant,atanytimewithinthepastfiveyears,derivedmorethan10%ofits
annualrevenueorfundingfromfederal,state,local,foreignorothergovernmentalorquasi-governmentalsources?
Yes No
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7.DoestheApplicanthaveanydirectorindirectinsuranceoperations?
Yes No
8.DoestheApplicantperformanyprofessionalservicesforafee?
Yes No
9.IstheApplicantformedasapartnershiporlimitedpartnershipordoesitoranyofits
SubsidiariesactasaGeneralPartnerforanotherorganization?
Yes No
Iftheanswertoanyquestionaboveis“Yes,”pleaseattachdetails.
PastActivities
10.HastheApplicantoranypersonproposedforcoveragebeenthesubjectof,orbeen
involvedin,anyofthefollowingduringthepastfiveyearsa)Anti-trust,copyrightorpatentlitigation?b)Deceptivetradepracticesorconsumerfraud?c)Civil,criminaloradministrativeproceedingallegingviolationofanyfederalorstate
securitieslaws?d)Anyothercriminalactions?
Yes No Yes No Yes No
Yes No
11.OtherthanthoseidentifiedinQuestion10above,hasanypersonorentityproposedforcoveragebeenthesubjectof,orinvolvedin,anylitigation,administrativeproceeding,demandletter,orformalorinformalgovernmentalinvestigationorinquiry?
Yes No
Iftheanswertoanyquestionaboveis“Yes,”pleaseattachdetails.
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EmploymentPracticesLiabilityCoverageSectionQuestionsPlease answer the following questions if Employment Practices Liability coverage is beingrequested
EmployeeCount1. Domestic(U.S.)Employees: CurrentYear PriorYear
a) Full-time b) Part-time(includingleasedandseasonal) c) Independentcontractors d) Unpaidinterns/apprentices e) Numberorpercenthourlyemployees f) Numberofemployeesina-cabovelocatedinCA g) Numberofemployeesina-cabovelocatedinFL,MS,NJ,NY,TN,WV
2. Foreign(nonU.S.)Employees: 3. ChangesinWorkforce:
a) HastheApplicanthadduringthepast12months(oristheApplicantplanninginthenext12months)anylayoffs,officeorfacilityclosures,orreductionsinworkforce?
b) Havemorethan25%oftheApplicant’sofficersorseniormanagementleftthecompanyinthepast18months?
Yes No
Yes No
Iftheanswerto3.a)orb)aboveis“Yes,”pleaseattachdetails.U.S.SalaryRanges4. EmployeeSalaryRanges: %ofEmployeesinRange
CurrentYear%ofEmployeesinRangePrior
YearUpto$50,500 $50,501to$120,000 Over$120,000
PoliciesandProcedures
5. DoestheApplicantpublishanemployeehandbookanddistributeittoevery
employee?
Yes No
6. DoestheApplicanthavewrittenproceduresinplaceregarding:
a) EqualEmploymentOpportunity?b) Discrimination?c) SexualHarassment?d) Handlingcomplaintsofsexualharassmentordiscrimination?
Yes No Yes No Yes No Yes No
Iftheanswertoanyquestionaboveis“No,”pleaseattachdetails.
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AdditionalquestionforApplicantswithmorethan250employees
7. Areallterminationsreviewedbya) HumanResources?b) Counsel(Internalorexternal)?
Yes No Yes No
8. Isthereafull-timehumanresourcesmanagerordepartment?
Yes No
9. DoestheApplicantconducttrainingregardingdiscriminationandsexualharassmentpoliciesandprocedures?
Yes No
10. Doeslaborrelationscounselreviewemploymentpolicies,procedures,andmaterialatleastannually?
Yes No
11. IftheApplicantisorhasbeenafederalcontractor,hastheApplicantbeensubjecttoanOFCCP(OfficeofFederalContractCompliancePrograms)audit?
Yes No Not Applicable
12. DoestheApplicanthavewrittenproceduresinplaceregarding:a) Employmentatwill?b) ADA(AmericanswithDisabilitiesAct)accommodations?
Yes No Yes No
13. Arecriminalbackgroundchecksusedinthehiringprocess? Yes No
Iftheanswerto7–12is“No,”or13is“Yes,”pleaseattachdetails.
PastActivities
14.Inthepastthreeyears,hasanyApplicant,inanycapacity,beeninvolvedinanyofthefollowingmatters?
a)EEOC(EqualEmploymentOpportunityCommission)orothersimilaradministrativeproceeding,regulatoryactionorinvestigation
b)Employment-relatedcivilsuitorclaim
Yes No
Yes No
If“Yes,”pleaseattachdetails.
HumanResourcesManager,orHumanResourcescontactinformation(forHelplineServices):____________________________________________________________________________________________________________________________________________________________________________________________________
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FiduciaryLiabilityCoverageSectionQuestionsPlease answer the following questions if Fiduciary Liability coverage is being requested
Planinformation:InthetablebelowpleaselistthenamesandtypesoftheApplicant’semployeebenefitplan(s).Attachadditionalpages,ifneeded.TypeofPlan:DC=DefinedContributionPension(forexamplea401(k)plan),DB=DefinedBenefitPension,W=Welfare,O=Other
NameofPlan(asitappearsonForm5500,ifapplicable)
CurrentMarketValueofAssets(ifapplicable)
TypeofPlan
IsanyplananESOPoratanytimeinthepast36monthshaveassets
beenheldorpermittedtobeinvestedin
EmployerSecuritiesorisanysuchinvestment
expectedinthenext12months(Yes/No)*
TotalNumberofParticipants
NameofInvestmentManager**
*ESOPmeansEmployeeStockOwnershipPlanandEmployerSecuritiesmeanssecuritiesoftheApplicant,theparentoftheApplicant,anycompanythatisacquiredinwholeorinpartbytheApplicant,oranyformerparentofanycompanythatisacquiredinwholeorinpartbytheApplicant.**“InvestmentManager”isthepartygrantedcontroloforauthoritytoinvestplanassets.
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1.CurrentmarketvalueofassetsofallSponsoredPlansforwhichcoverageisrequested: $___________________
2.Inthepast24months,hasanyamendment(s)toanyplanbeenmadeorconsideredthathasresultedin,ormayresultin,areductionofbenefits,includingbutnotlimitedtoachangeintheformulaforcalculatingbenefits,acessationofmedicalorpost-retirementbenefits,oranincreaseinparticipants’ortheplan’sshareofcosts?
Yes No
3.Hasanyplanorpartofaplan,beentransferred,merged,orterminatedorisanysuchactivityunderconsideration? Yes No
4.Arethereanyoverdueemployercontributionsforanyplan,orhasarequestforawaiverofcontributionsbeenmadeorcontemplatedforanyplan? Yes No
5.ArealldefinedbenefitplansadequatelyfundedinaccordancewithERISAorapplicablesimilarcommonorstatutorylawoftheUnitedStates,Canada,theUnitedKingdom,oranystateorotherjurisdictionanywhereintheworld?
Yes No
Not Applicable
Iftheanswerto2,3or4is“Yes”ortheanswerto5is“No,”pleaseattachdetails.
PastActivities6.Inthepastthreeyearshastherebeenanyclaim,lawsuitorregulatoryactionagainst,or
regulatoryinvestigationorinquiryofanypersonorentityproposedforcoverage,arisingoutofanyplanorallegingaviolationofERISAorEmployeeBenefitLaw?
Yes No
If“Yes,”pleaseattachdetails.
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EmployedLawyersLiabilityCoverageSectionQuestionsPlease answer the following questions if Employed Lawyers Liability coverage is being requested
CurrentYear
PreviousYear
1. TotalnumberofEmployedLawyers(includingtemporaryandcontractattorneys)
2. DoanyofEmployedLawyersprovidelegalservicesinthefollowingpracticeareas:
a) EnvironmentalLawandCompliance?b) Copyright,Patent,Trademarkand/orotherintellectualpropertylaw?c) Litigation?d) SecuritiesLaw?
Yes No Yes No Yes No Yes No
3. DoanyEmployedLawyersprovideMoonlightingLegalServices?
Yes No
4. Hasanypersonproposedforthiscoveragebeenthesubjectof,orbeeninvolvedin,
anyofthefollowingarisingoutofhisorherprovisionoflegalservices,irrespectiveofwhethersuchactivityaroseoutofworkperformedfortheApplicant:a) Anyreprimand,sanction,fineordisciplineby,orrefusedadmissionto,abar
association,court,administrativeorregulatoryagency?b) Anycivilorcriminallitigation,arbitration,claimoradministrativeorregulatory
proceedingduringthepastfiveyears?
Yes No
Yes No
If“Yes”toanyquestionabove,pleaseprovidedetails.
5. DescribethetypeofworktypicallyreferredbytheApplicanttooutsidecounsel
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CrimeCoverageSectionQuestionsPlease answer the following questions if Crime coverage is being requested
CurrentYear PreviousYear1. Totalnumberemployees
a)USb)Foreign
a)b)
a)b)
2. NumberofUSlocationsa) Retailb) Non-retail
a)b)
a)b)
3. NumberofForeignlocationsa) Retailb) Non-retail
a)b)
a)b)
4. BankAccountsa) Areallbankaccountsreconciledmonthly?b) Arebankaccountsreconciledbysomeonenotauthorizedtowithdraw?c) Iscountersignatureofallchecksrequired?d) Isthecashexposureatanysinglelocationinexcessofrequesteddeductible?
Yes No Yes No
Yes No Yes No
5.AuditProceduresa)DoestheApplicanthavean:InternalAuditDepartment?CorporateSecurityDepartment?ITAudit/NetworkSecurityDepartment?
b) Howoftenarealldomesticlocationsaudited?c) Howoftenareallforeignlocationsaudited?d) Doyouprovidefraudawarenesstrainingforallyourstaff?e) Werethereanymaterialissuesininternalcontrolsidentifiedduringanyofthe
Applicant’sinternalorexternalauditsinthepastthreeyears?Ifyes,pleaseexplainactionstakentoaddressthoseissues.
Yes No Yes No Yes No
Yes No
Yes No
6.Computer/FundsTransferControlsa)Whatisthemaximumdollarvalueofwiretransfersperlocation?b)Doallwiretransfersrequireatleastdualapproval?c)Doallnon-repetitivewiretransfersrequireapprovedpurchaseordersandother
supportingdocumentation?d)HowoftendoestheApplicantrequirecomputeraccesscodesandpasswordsbe
changed?e)HaveanyvendorsorotherthirdpartiesbeengivenaccesstotheApplicant’s
computersysteminthepastthreeyears?f)(i)HastheApplicant’scomputersystems/ITdepartmentbeenauditedbyathirdparty
inthepastyear?(ii)Ifyes,werethereanyissuesbroughtupthatrequiredimmediateattention?
Iff)(ii)is“Yes,”pleaseprovidedetailsofactionstakentoaddressthoseissues.
________________
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
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g)Doestheapplicantprovideanytypeof“SocialEngineeringFraud”trainingtotheir
employees?h)HowdoestheapplicantverifytheauthenticityandaccuracyofallFundsTransfer
requests?__________________________________________________________________________________________________________________________________________
Yes No
7. VendorControlsa) DoestheApplicantmaintainalistofallapprovedvendorsonaglobalbasis?b) DoestheApplicantperformbackgroundchecksonitsvendors?c) ArethereanyvendorsoftheApplicantthatwerenotsubjecttoabackgroundcheck?d) Doallpurchaseordersrequiredualapproval?e) HowdoestheApplicantverifytheauthenticityandaccuracyofanychangesmadeto
avendorsaccountconcerningbankaccountinformation,contactinformation,phoneinformation?__________________________________________________________________________________________________________________________
Yes No Yes No Yes No Yes No
8. Clients’Property(completeifrequestingcoverage)a) WhattypeofworkwilltheApplicantbedoingforitsclients?
___________________________________________________________________b) Willthisworkbeprovidedontheclients’premises?c) WilltheApplicant’semployeeshaveaccesstomoney,securitiesortangibleproperty
ofitsclients?d) WhatcontrolsareinplacetoprotecttheApplicant’sclientsfromemployeetheft?
___________________________________________________________________
___________________________________________________________________
Yes No
Yes No
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FRAUDWARNING
DCONLY:ITISACRIMETOPROVIDEFALSEORMISLEADINGINFORMATIONTOANINSURERFORTHEPURPOSEOFDEFRAUDINGTHEINSURERORANYOTHERPERSON.PENALTIESINCLUDEIMPRISONMENTAND/ORFINES.INADDITION,ANINSURERMAYDENYINSURANCEBENEFITS,IFFALSEINFORMATIONMATERIALLYRELATEDTOACLAIMWASPROVIDEDBYTHEAPPLICANT.FLONLY:ANYPERSONWHOKNOWINGLYANDWITHINTENTTOINJURE,DEFRAUD,ORDECEIVEANYINSURERFILESASTATEMENTOFCLAIMORANAPPLICATIONCONTAININGANYFALSE,INCOMPLETE,ORMISLEADINGINFORMATIONISGUILTYOFAFELONYOFTHETHIRDDEGREE.LAONLY:ANYPERSONWHOKNOWINGLYPRESENTSAFALSEORFRAUDULENTCLAIMFORPAYMENTOFALOSSORBENEFITORKNOWINGLYPRESENTSFALSEINFORMATIONINANAPPLICATIONFORINSURANCEISGUILTYOFACRIMEANDMAYSUBJECTTOFINESANDCONFINEMENTINPRISON.MDONLY:ANYPERSONWHOKNOWINGLYORWILLFULLYPRESENTSAFALSEORFRAUDULENTCLAIMFORPAYMENTOFALOSSORBENEFITORWHOKNOWINGLYORWILLFULLYPRESENTSFALSEINFORMATIONINANAPPLICATIONFORINSURANCEISGUILTYOFACRIMEANDMAYBESUBJECTTOFINESANDCONFINEMENTINPRISON.NJONLY:ANYPERSONWHOINCLUDESANYFALSEORMISLEADINGINFORMATIONONANAPPLICATIONFORANINSURANCEPOLICYISSUBJECTTOCRIMINALANDCIVILPENALTIES.NYONLY:ANYPERSONWHOKNOWINGLYANDWITHINTENTTODEFRAUDANYINSURANCECOMPANYOROTHERPERSONFILESANAPPLICATIONFORINSURANCEORSTATEMENTOFCLAIMCONTAININGANYMATERIALLYFALSEINFORMATION,ORCONCEALSFORTHEPURPOSEOFMISLEADING,INFORMATIONCONCERNINGANYFACTMATERIALTHERETO,COMMITSAFRAUDULENTINSURANCEACT,WHICHISACRIME,ANDSHALLALSOBESUBJECTTOACIVILPENALTYNOTTOEXCEEDFIVETHOUSANDDOLLARSANDTHESTATEDVALUEOFTHECLAIMFOREACHSUCHVIOLATION.PAONLY:ANYPERSONWHOKNOWINGLYANDWITHINTENTTODEFRAUDANYINSURANCECOMPANYOROTHERPERSONFILESANAPPLICATIONFORINSURANCEORSTATEMENTOFCLAIMCONTAININGANYMATERIALLYFALSEINFORMATIONORCONCEALSFORTHEPURPOSEOFMISLEADING,INFORMATIONCONCERNINGANYFACTMATERIALTHERETOCOMMITSAFRAUDULENTINSURANCEACT,WHICHISACRIMEANDSUBJECTSSUCHPERSONTOCRIMINALANDCIVILPENALTIES.OKONLY:ANYPERSONWHOKNOWINGLY,ANDWITHINTENTTOINJURE,DEFRAUDORDECEIVEANYINSURER,MAKESANYCLAIMFORTHEPROCEEDSOFANINSURANCEPOLICYCONTAININGANYFALSE,INCOMPLETEORMISLEADINGINFORMATIONISGUILTYOFAFELONY.ORONLY:ANYPERSONWHOMAKESANINTENTIONALMISSTATEMENTTHATISMATERIALTOTHERISKMAYBEFOUNDGUILTYOFINSURANCEFRAUDBYACOURTOFLAW.ALLOTHERSTATES:ANYPERSONWHOKNOWINGLYANDWITHINTENTTOINJURE,DEFRAUD,ORDECEIVEANYINSURANCECOMPANYORANOTHERPERSONFILESANAPPLICATIONFORINSURANCEORSTATEMENTOFCLAIMCONTAININGANYMATERIALLYFALSEINFORMATION,ORCONCEALSFORTHEPURPOSEOFMISLEADINGINFORMATIONCONCERNINGANYFACTMATERIALTHERETO,COMMITSAFRAUDULENTINSURANCEACT,WHICHISACRIMEANDSUBJECTSTHEPERSONTOCRIMINALANDCIVILPENALTIES.INCO,ME,TN,VA,ANDWA,INSURANCEBENEFITSMAYALSOBEDENIED.
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ThisquestionisapplicabletotheDirectorsandOfficersCoverageSectionifnocoverageiscurrentlymaintained.Doesanypersonorentityforwhomthisinsuranceisintendedhaveanyknowledgeorinformationofanyact,error,omission,factorcircumstancewhichareasonablepersonwouldbelievemaygiverisetoaClaimwhichmayfallwithinthescopeofthisproposedcoveragesection? Yes NoThisquestionisapplicabletotheEmploymentPracticesCoverageSectionifnocoverageiscurrentlymaintained.Doesanypersonorentityforwhomthisinsuranceisintendedhaveanyknowledgeorinformationofanyact,error,omission,factorcircumstancewhichareasonablepersonwouldbelievemaygiverisetoaClaimwhichmayfallwithinthescopeofthisproposedcoveragesection? Yes No
ThisquestionisapplicabletotheFiduciaryLiabilityCoverageSectionifnocoverageiscurrentlymaintainedDoesanypersonorentityforwhomthisinsuranceisintendedhaveanyknowledgeorinformationofanyact,error,omission,fact,circumstanceorviolationofERISAoremployeebenefitlawwhichareasonablepersonwouldbelievemaygiverisetoaClaimwhichmayfallwithinthescopeofthisproposedcoveragesection? Yes No
ThisquestionisapplicabletotheEmployedLawyersCoverageSectionifnocoverageiscurrentlymaintainedDoesanypersonorentityforwhomthisinsuranceisintendedhaveanyknowledgeorinformationofanyact,error,omission,factorcircumstancewhichareasonablepersonwouldbelievemaygiverisetoaClaimwhichmayfallwithinthescopeofthisproposedcoveragesection? Yes No
If“Yes”toanyquestionabove,pleaseprovidedetails.
ITISAGREEDTHATIFSUCHKNOWLEDGEORINFORMATIONEXISTS,ANYCLAIMARISINGTHEREFROM(WHETHERORNOTDISCLOSEDHEREIN),ISEXCLUDEDFROMTHEPROPOSEDCOVERAGE.SUCHEXCLUSIONWILLNOTOPERATEASAWAIVEROFANYOTHERREMEDIESTHEINSURERMAYHAVE.ITISFURTHERAGREEDTHATTHISSTATEMENTMADETHEREONSHALLBEDEEMEDANEXPRESSWARRANTYFORALLINSUREDSWHICHHASBEENRELIEDUPONBYTHEINSURERPURSUANTTOTHEISSUANCEOFCOVERAGE.
THEUNDERSIGNEDISANAUTHORIZEDREPRESENTATIVEOFTHEAPPLICANT,ANDHEREBYCERTIFIESTHATTHEYHAVEMADEREASONABLEINQUIRIESTOOBTAINANDPROVIDETHEANSWERS,INFORMATIONANDDOCUMENTATIONTHATISRESPONSIVETOTHEQUESTIONSANDREQUESTSCONTAINEDINTHISAPPLICATION,ANDREPRESENTSTHATTHEANSWERS,INFORMATIONANDDOCUMENTATIONISTRUE,ACCURATEANDCOMPLETETOTHEBESTOFTHEIRKNOWLEDGEANDBELIEF.__________________________________________________________________________SignatureofChiefExecutiveOfficer,ChiefFinancialOfficer,orPresidentoftheApplicant__________________________________________________________________________PrintName/Title___________________________Date