DIRECTORS & OFFICERS INSURANCE | AHERN Insurance Brokerage | Full-Service Insurance Brokerage Firm

With an uptick in claims as related to Directors and Officers (D&O), it’s recommended D&O Insurance is considered. D&O Insurance is liability insurance payable to Directors and Officers of a company as indemnification for losses in the event an insured suffers as a result of legal action brought for alleged wrongful acts in their capacity as a Director & Officer.

Examples of Directors and Officers claims include:

Breach of fiduciary duty
Fraud
Failure to comply with workplace laws
Misuse of company funds
Lack of corporate governance

D&O Proposal Form

Step 1 of 6

Producer Information

Submitted by (Agency Name)

Dated

Agent’s Name (Individual’s Name)

Agent’s License Number

Please Read Carefully

The undersigned, acting on behalf of all proposed Insureds, declare that the statements set forth herein are true and correct and that thorough efforts have been made to obtain sufficient information from each Insured proposed for this insurance to facilitate the proper and accurate completion of this Proposal Form.
The undersigned agree that the particulars and statements contained in the Proposal Form and any information submitted herewith are their material representations and are the basis of the insurance contract. The undersigned further agree that the Proposal Form and any material submitted herewith shall be considered attached to and a part of the Policy. Any material submitted with the Proposal Form shall be maintained on file (either electronically or paper) with the Insurer and shall be deemed to be attached hereto as if physically attached.
It is further agreed that:
- if any significant change in the condition of the applicant is discovered between the date of this Proposal Form and the Policy inception date, which would render this Proposal Form inaccurate or incomplete, notice of such change will be reported in writing to the Insurer immediately;
- any Policy, if issued, will be in reliance upon the truth of such representations, provided, however, with respect to such statements and representations, no knowledge or information possessed by any Insured Person shall be imputed to any other Insured Person.
If any person or persons knew as of the Policy inception date that such declarations and statements contained in the Proposal Form(s) were untrue, inaccurate or incomplete, and such statements materially affect either the acceptance of the risk or the hazard assumed by the Insurer under this Policy, then this Policy shall not apply as to that person or persons. However, if the President, Chief Executive Officer, Chief Financial Officer or Managing Partner of the Insured Entity knew as of the Policy inception date that such declarations and statements contained in the Proposal Form(s) were untrue, inaccurate or incomplete, and such statements materially affect either the acceptance of the risk or the hazard assumed by the Insurer under this Policy, then this Policy shall not apply as to that person or persons and the Insured Entity;
- the information contained in this Proposal Form shall not be used by the Insureds as notice as provided for in section Vll. of the Common Policy Terms and Conditions Section of this Policy;
- this Proposal Form has been completed as respects the entire Insured Entity;
- the signing of this Proposal Form does not bind the undersigned to purchase the insurance.

Dated

President, Chief Executive Officer, Chief Financial Officer, or Managing Partner (Signature)

President, Chief Executive Officer, Chief Financial Officer, or Managing Partner (Print Name)

Title

Dated

Human Resources Manager, or equivalent position (Signature)

This Admiral Insurance Company Proposal Form, including any material submitted herewith, shall be held in strictest confidence.

A POLICY CANNOT BE ISSUED UNLESS THE PROPOSAL FORM IS PROPERLY SIGNED AND DATED

D&O Proposal Form

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