APPLICATION FOR DIRECTORS AND OFFICERS LIABILITY INSURANCE Copies of the following information must be attached to this application: Schedule of Directors and Officers including present positions; the organization's charter or by-laws; the organization's latest audited financial statement; the organization's latest interim report Name of Applicant: ____________________________________________ Address: ____________________________________________ Date organized: ______________________ Conducted business continuously since: _____________________ Legal Structure: Corporation or Association or Foundation or Professional or Trade or Service Purpose of the organization and nature of operations: _________________________________________________________________ _________________________________________________________________ Limit of liability requested: $ ____________________________ The director or officer designated to receive any and all notices from the Insurer or their representatives concerning this insurance is: Name: ____________________________________________ Mailing Address: ____________________________________________ Size of operating budget (revenue plus cash assets): $ ____________________________________________ Indicate the percentage of funds received from the following sources: Federal, provincial, local government: ____________ Other (please specify): ____________ Fees for services: ____________ Are contributions generally solicited? YES or NO Dues from Members: ____________ What percentage to total contributions received are available for charitable purposes? ____________ Donations, contributions from the general public ____________ Indicate number of: Directors: ____________ Officers: ____________ Professionals: ____________ Clerical Employees: ____________ Volunteers: ____________ Members: ____________ Does the organization have any stockholders or persons who profit from the operation except as salaried employees? YES or NO If yes, provide full details: _________________________________________________________________ _________________________________________________________________ List all subsidiaries and affiliated organizations indicating whether profit or non-profit and nature of operations: _________________________________________________________________ _________________________________________________________________ Does the organization have any operations outside Canada? YES or NO If yes, provide full details: _________________________________________________________________ _________________________________________________________________ Name of auditor/accountant: ____________________________________________ How often is an audit done?: ____________________________________________ Has the organization changed its auditor/accountant in the last five years? YES or NO If yes, provide details: _________________________________________________________________ _________________________________________________________________ Has the organization filed a Federal income tax return for any of the last five years? YES or NO If yes, have the returns been accepted as filed? YES or NO If no, provide full details: _________________________________________________________________ _________________________________________________________________ Are any of the Directors or Officers or any other person(s) proposed for this insurance indebted to the Organization? YES or NO If yes, provide full details: _________________________________________________________________ _________________________________________________________________ How frequently does the Board of Directors meet? __________________ How many board members must be present to constitute a quorum? __________________ Are meeting agenda and minutes of previous Board meetings and Board committee meetings distributed to each director at least 10 days prior to each Board meeting date? YES or NO Describe the procedures which are in place to keep the Directors and Officers informed of new developments, operations results, etc., between meetings _________________________________________________________________ _________________________________________________________________ Does each Director have a formal job description which clearly defines his/her scope of duties YES or NO What are the Corporation's rules with respect to loans on behalf of the Organization? _________________________________________________________________ _________________________________________________________________ Indicate the source of the Board's legal advice: ____________________________________________ Do the Board's legal advisors make regular presentations to the Board to review the responsibilities of the Directors and Officers and of the organization, as defined in the various relevant statutes and related jurisprudence? YES or NO Are all Directors, Officers and senior employees required to obtain legal counsel prior to publicity commenting on any of the Corporation's activities? YES or NO Provide details of current or expiring liability coverages: Insurer Policy Period Limit Commercial General Liability _________________ _________________ _________________ Professional Errors & Omissions _________________ _________________ _________________ Other: _________________ _________________ _________________ _________________ Provide details of Association Errors & Omissions Liability Insurance carried in the past three years: Insurer Policy Period Limit Deductible Premium _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ During the past five years, has the organization had similar insurance declined, cancelled, non-renewed or refused? YES or NO If yes, provide full details: _________________________________________________________________ _________________________________________________________________ Has any claim been made or is a claim now pending against the organization or any person proposed for the insurance? YES or NO If yes, provide full details: _________________________________________________________________ _________________________________________________________________ Has any suit or legal action been filed by or on behalf of the organization against any person(s) proposed for this insurance? YES or NO If yes, provide full details: _________________________________________________________________ _________________________________________________________________ Does the organization or any other person(s) proposed for this insurance have knowledge or information of any actual or alleged negligent act, error, omission, misstatement or misleading statement or breach of duty which might give rise to a future claim? YES or NO If yes, provide full details: _________________________________________________________________ _________________________________________________________________ It is agreed that any claim or action arising from any negligent act, error or omission, misstatement or misleading statement, or breach of duty which is known to any Director or Officer prior to issuance of the policy shall be excluded from coverage. DECLARATION The undersigned declares that all statements made in the Application and the information contained in documents submitted with it are true. The under signed also declares that all officers and directors acknowledge the contents of Question 18 and that each of them has attested to the accuracy of the response given. Signing of this document does not bind the Applicant to complete the insurance, but it is agreed that the Applicant shall be the basis of the contract, should a policy be issued. SIGNED, SEALED AND DELIVERED this _________ day of ________________ 19 _________ . ______________________________________ ______________________________________ Corporation Chairman of the Board or President HUBBARD INSURANCE BROKERS 100 MATHESON BLVD. E. SUITE #103 MISSISSAUGA, ONTARIO L4Z 2G7 PH# (905) 712-4668 FAX# (905) 712-3586

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