Directors and Officers Liability Insurance

Directors' and Officers' Liability Insurance
Quote

COPIES OF THE FOLLOWING INFORMATION MUST BE INCLUDED WITH THIS FORM

Last three years' audited annual reports.
Latest interim report or budget statement for the current year.
List of Directors, Officers and Members of duly constituted committees

Please answer all questions on this form, print it out, sign it, and mail to us with the above information.

Name of Corporation:
Address:
Province: *		Postal Code:
Contact Name:
Telephone:
E-mail: *

THE CORPORATION
Nature of services:
Date of Incorporation: mm-dd-yy
Jurisdiction:
Fiscal year end:
Conducted business since: (mm-dd-yy)
Please identify the source of funds and percent revue for each:
Membership Dues:	%
Donations:	%
Government grants:	%
Other: (specify)
	%
	%
	%
Does the Corporation have any subsidiaries or affiliated companies?	Yes No
Please provide information regarding the number of: Directors:
Officers:
Volunteers:
Management personnel:
Employees:
Has the Corporation, at any time in the past five years, been in breach of any of its debt covenants or loan agreements?	Yes No
Has the Corporation, at any time in the past five years, been in arrears in its payments to Revenue Canada or the provincial ministers of revenue (including source deductions, GST and PST)?	Yes No
Has the Corporation, at any time in the past five years, changed its accountants or external legal advisors?	Yes No
Does the Corporation carry out any disciplinary action, review activities or issues licences and/or permits?	Yes No
Does the Corporation act in any capacity as an insurance agent, broker, underwriter, or consultant?	Yes No
Does the Corporation publish any magazines, periodicals or bulletins?	Yes No
Does the Corporation publish a technical manual?	Yes No
On behalf of itself or its members, does the Corporation engage in advertising, broadcasting or reproduction of copyright?	Yes No
If 'Yes" to any of the above, please give details:
Are any loans outstanding or anticipated to any person(s) applying for insurance in their capacity as either a director, trustee, officer, employee or committee member of the Corporation or Corporations controlled by them?	Yes No
What are the Corporation's rules with respect to loans described in the preceding question?
How frequently does the Board of Directors meet?
How many Board members must be present for a quorum?
Are meeting agenda and minutes of the previous Board meetings distributed to each director at least 10 days prior to each Board meeting?	Yes No
Describe the procedures which are in place to keep directors and officers informed of new developments, operational results, etc, between meetings.

YEAR 2000 (Y2K) RISK PROFILE
Did you have a written Y2K compliance plan in place to ensure that your systems would be Y2K compliant?	Yes No
Has the Corporation had any Y2K related problems? If yes, please explain:	Yes No
Do you have a senior executive responsible for Y2K related problems?	Yes No
Do you have a contingency plan in place in the event that your systems are not Y2K Compliant?	Yes No
Do your company's audited annual financial statements disclose that the Y2K issue is being addressed?	Yes No
Prior to completing mergers or acquisitions, do you require assurances from merger targets that they are Y2K Compliant?	Yes No
Has the Corporation provided assurances to any customers, clients or other business partners that it is Y2K Compliant?	Yes No

PRIOR INSURANCE / PAST ACTIVITIES
Provide details of Corporation's current or expiring insurance coverages:
	Name of Insurer	Limit of Policy	Expiry	Claims
Directors and Officers Liability
Professional Indemnity
General Liability

Is the Corporation or any person(s) applying for this insurance involved in or have any knowledge of any anti-trust, combines, price-fixing, restraint of trade, tax, copyright, patent infringement or government regulatory or administrative proceedings? If Yes, Please provide details:	Yes No
Has the Corporation or any person(s) applying for this insurance given written notice under the provisions of any prior or current Director's and Officers liability insurance policy of any claim made or any specific circumstances which may be expected to give rise to a claim being made? If "Yes", provide details:	Yes No
Has similar insurance on behalf of the Corporation been declined or cancelled or renewal refused? If "Yes", provide details:	Yes No
Have any loss payments been made on behalf of any person(s) or entity(ies) proposed for insurance under any insurance policy similar to that now proposed? If "Yes", provide details:	Yes No
Has any claim been made or is now pending against any person(s) or entity(ies) proposed for this insurance which would have fallen within the scope of such insurance had insurance similar to that now proposed been in force? If "Yes", provide details:	Yes No
THE APPLICANT
Is the Corporation or any person(s) proposed for this insurance cognizant of any Wrongful Act she/he has reason to suppose might afford grounds for any future claim such as would fall within the scope of this proposed insurance? If "Yes", provide details:	Yes No
REMEMBER TO ATTACH: Last three years' audited annual reports. Latest interim report or budget statement for the current year. List of Directors, Officers and Members of duly constituted committees

____________________________________________ Date	____________________________________________ Corporation
____________________________________________ Duly Authorized Signing Officer	____________________________________________ Signature of Signing Officer

INSTAR Insurance Brokers Inc.
2435 Holly Lane, Suite 200
Ottawa, ON K1V 7P2
Tel. 613-228-1600
Fax: 613-232-6486
Email: info@instar.on.ca