Directors & Officer's Liability and Employment Practices Liability Pennsylvania Only

1) Are there any subsidiaries:  Yes  /  No
    If "YES", please provide name, date established, location, operations, ownership, assets, number of employees:

2) Current and Prior Insurance

COVERAGE	INSURANCE COMPANY	EXPIRATION DATE	PREMIUM	LIMITS / RETENTION LIMIT
Directors & Officers				/
Employment Practices				/
Errors & Omissions				/
Fiduciary				/
Crime				/

3. Ownership. If any response is “Yes”, please explain fully in an attachment to this application.
    a) Number of shares outstanding. Voting       Non Voting 
    b) Number shareholders or members. Voting  Non Voting 
    c) Number of shares/interests owned by the directors and officers (direct and beneficial). 
    d) Is the applicant a Subsidiary of another Organization?  Yes /  No
Name of Parent. 
    e) Does any shareholder own 10% or more of the voting shares directly or beneficially . . . . . . . . . . . . . . .  Yes /  No
        Please e-mail a list of names and percentage ownership interest.
    f) Are there any other securities that are convertible to voting stock? . . . . . . . . . . . . . . . . . . . . . . . . . . ..  Yes /  No
   g) Have any shares of the Organization been publicly traded within the last 3 years? . .. . . . . . . . . . . . . . .  Yes /  No

4. Management. If “Yes”, please explain fully in an attachment to this application.
   a) 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 /  No
   b) Has the Organization changed outside auditors in the last 3 years? . . . . . . . . . . . . . . . . . . . . . . . . . .  Yes /  No
   c) Have any auditors found any material weaknesses in Organization's system of internal controls? . . . . .  Yes /  No
   d) Has the Organization violated or breached any debt covenant, loan agreement
        or other material obligation in the past 3 years? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Yes /  No

5. 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?
    If “Yes”, please explain fully.
    a) Merger, acquisition or consolidation with another entity? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Yes /  No
    b) Sale, distribution or divestiture of more than 25% of assets or stock of the Organization? . . . ........ .  Yes /  No
    c) Any registration for a public offering? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .  Yes /  No
    d) Any private placement? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... . .  Yes /  No
    e) Reorganization or formal arrangement with creditors? . . . . . . . . . . . . . . . . . . . . . . . . . . . .  . . . . . .  Yes /  No

6. Total number of employees.
 

	Current  12 months	Prior 12 months	Anticipated next 12 months (If operating less than 5 years)
Full Time:
Part Time:
Temporary/Seasonal:
Independent Contractors:
Leased:

7. Is more than 20% of the Organization's work force located in another state?  Yes /  No
   If yes, please provide the number of workers at each location.

8. Percentage of employees with total compensation including salaries, bonuses and commissions?
    $51,000 to $100,000:         Over $100,000: 

9. Has the Organization closed any facilities, downsized, laid off or reduced staff in the past 12 months?  Yes /  No
    Does the Organization anticipate doing so in the next 12 months?  Yes /  No
   If yes, please attach details.

10. Number of employees involuntarily terminated or laid off in the past 12 months? 
                                                                                               past 24 months? 

11. Within the last 5 years has any employment related, third party harassment or third party discrimination claim, suit, inquiry,
complaint or notice of hearing been made against the Organization or any individual proposed for Insurance?  Yes /  No

12. Within the last 5 years, has any claim, suit inquiry, complaint or notice of hearing been made against the Organization or
any person proposed for Insurance in the capacity of Director, Officer, or Employee of the Organization?  Yes /  No

13. 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 /  No

Please complete the following if Employment Practices Liability requested:
Mandatory Written Employment Policies. Please identify policies Applicant has in place:
Anti-Harassment Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Yes /  No
Anti-Discrimination Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Yes /  No

Please forward copies of the policies identified above with this signed and dated application. If you do not have these written policies in place, the Company will provide sample wording at the time of binding this insurance. Policies must apply to employees and contractors, vendors, customers and other third parties if Third Party Discrimination is purchased.

Recommended Written Employment Policies. Please identify policies Applicant has in place:
     Employment Application . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Yes /  No
     Employee Handbook. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Yes /  No
     E-mail/Internet Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Yes /  No
If Applicant has an Employee Handbook, Employment Application or E-Mail/Internet Policy, a copy of the Contractual Disclaimer and Employment At Will statements in the Handbook, the employment application and the E-Mail/Internet Policy must be forwarded to the Company for review.

As a condition precedent to issuance of the Policy for Insurance the Applicant agrees:

1. to implement and distribute to each employee the Mandatory Written Policies identified above which are currently not in place as  soon as possible, but no later than 21 days after the inception date of this insurance. Failure of the Company to receive these policies within 21 days after the inception date of this insurance will result in rescission of the binder for this insurance.
2. to adopt and distribute to each employee all changes required by the Company to the Applicant's Written Policies, as soon as possible, but no later than 21 days after receipt of notice of the changes required by the Company.