Directors & Officers Liability

Personal Details

Agreement

Risk Details

General Policy Details

Personal Details

Proposer Type

Bank Assurance Officer

Select Intermediary branch

Insurance Company

ID Type

ID Number

KRA Pin

First Name

Middle Name

Last Name

Type of Business

Occupation

Date Of Birth

Gender

Male Female

Contact Details

Mobile No.

Telephone No.

Email Address

Postal Address

Postal Office

Town

County

Region

Earth Quake Zone

Physical Address

Which FBBI branch do you want to be served from?

Non-Disclosure/Misstatement/Misrepresentation It is the duty of the proposer to disclose all material facts relevant to the risk. A material fact is one that is likely to influence our judgment and acceptance of your proposal. If your proposal is a renewal it should include any change in facts previously advised to us. If you are in any doubt about facts considered material, disclose them. Please note that failure to disclose a material fact or if any information provided proves to be incorrect may invalidate this insurance or any claim made under it.

I agree to the statement mentioned above

Risk Details

Insurance Start Date

Insurance End Date

Location Details

Name of Building

Name of Street

Area/Estate

City/Town

County

What is the policy holder’s business activity?

Is the policy holder is a legal entity?

Please provide directors and officers details

Name of the Directors / Officers

Duties/Role

Add

For how many years has the policy holder been in business?

Has the proposed policy holder ever been declared bankrupt or insolvent?

History of the Company

During the last five years has:

The name of the company changed?

Any acquisition or merger involving the company taken place?

Any subsidiary company been sold or ceased trading?

The capital structure of the company changed?

Any right issue taken place?

The company changed its external auditors or legal advisers?

Structure of the Company

Is the company:

Private

Public

Listed on the London Stock Exchange?

Listed on any other Stock Exchange?

Country

Stock Exchange

Please list all shareholdings representing 15% or more of the company’s ordinary share capital and their respective percentage of the holding.

Name of the Share Holder

Percentage of Shareholding

Add

Forward looking

Does the company have any acquisitions, tender offers or merger pending or under consideration?

Is the company aware of any proposal relating to its acquisition by another company in the next year?

Is the company intending a public or private offering of securities within the next year?

Current insurance arrangements

Does the company have directors & officer’s liability insurance currently in force?

North America exposure details

(Note: This section is to be completed only if cover is required for claims made in the United States of American or Canada or claims made elsewhere arising out of the company’s operations in United States of American or Canada.)

(i). Please state the TOTAL asset of all subsidiaries located in the USA / Canada

(ii). Please list those subsidiaries in the USA / Canada that are not wholly owned together with the company’s percentage interest in each and show the owner of minority interest

(iii). Do any of the subsidiaries have any stock, shares or debentures in USA / Canada?

(iv). Was the offer subject to the United States Securities Act of 1933 and/or any amendments there to?

(v). Does the company or any of its subsidiaries have any debt instruments or commercial paper in USA/Canada?

Claims History

Has there been, or is there now pending any claim against Director or officer of the company?

Is the proposer aware, after enquiry, of any circumstance or incident, which may give rise to claim against any director or officer of the company in such capacity?

Is the proposer aware, after prosecution (after or pending) of the company or any director or officer?

Has the company or any director or officers ever been subjected to any disciplinary action, been fired and penalized, or been the subject of any regulatory investigation and enquiry?

Limit of Liability

General Policy Details

Are you now or have you ever been insured for this type of policy ?

Has any insurance company ever

Declined your proposal ?

Cancelled or refused to renew your policy?

Required an increased premium or imposed special conditions?

Declined your claim?

Insurance and Loss History

Please provide below information on any insurance claims you have reported in the last 5 years

Type of loss

Year of Incident

Claim Amount/ Value

Add Loss

DECLARATION | Please Read Carefully *

I/ We do hereby declare that the above answers and statements are true and that I/ We have withheld no material information regarding this proposal. I/ We agree that this declaration and the answers given above as well as any proposal or declaration or statement made in writing by me/ us or anyone acting on my/ our behalf shall form the basis of the contract between me/ us and the Company. I/ We further agree to accept indemnity subject to the conditions in and endorsed on the Company’s policy.

CREDIT INFORMATION | Please Read Carefully *

I/we do hereby confirm that I/we have authorized Family Bank Insurance Agency to share my/our credit information and to access my/our credit profile from Credit Reference Bureau (C.R.B)

Directors & Officers Liability Proposal

Personal Details

Contact Details

Risk Details

Location Details

Please provide directors and officers details

History of the Company

Structure of the Company

Please list all shareholdings representing 15% or more of the company’s ordinary share capital and their respective percentage of the holding.

Forward looking

Current insurance arrangements

North America exposure details

Claims History

Limit of Liability

General Policy Details

Has any insurance company ever

Insurance and Loss History

DECLARATION | Please Read Carefully *

CREDIT INFORMATION | Please Read Carefully *