ࡱ> >@9:;<= @ kbjbjʚʚ CFJtttttttd|DDDȑ$|NF(nnn}1*,,,,,,$RKPqt}Pttnnwww@tntn*w*wwtt>n @^fDɴd >0,I-:I>d<@ttttIt> wn PP||E J$Eg|| JNon-Profit Organization Directors & Officers and Entity Coverage Liability Insurance ApplicationING Insurance Company of CanadaSuite 1500, 700 University Avenue, Toronto, Ontario M5G 0A1 NOTICE THE POLICY YOU ARE APPLYING FOR IS A CLAIMS-MADE POLICY AND IS SUBJECT TO ITS TERMS AND CONDITIONS. PLEASE REVIEW THE POLICY CAREFULLY AND DISCUSS THE COVERAGE WITH YOUR INSURANCE BROKER. INSTRUCTIONS FOR COMPLETING THIS APPLICATION Please read this application carefully. All questions are to be answered as completely as possible. If a question is not applicable to your situation state N.A. If insufficient space, attach full details. All information and all submitted materials will be held in confidence. 1. Name of Organization: FORMTEXT      Address (Number/Street/City/Province/Postal Code): FORMTEXT      Website Address: FORMTEXT      2. a) Is this Organization incorporated?With share capital?  FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMCHECKBOX  Yes  FORMCHECKBOX  No b) What is Organization s legal structure?  FORMCHECKBOX  Corporation  FORMCHECKBOX  Association  FORMCHECKBOX  Foundation  FORMCHECKBOX  Trust  FORMCHECKBOX  Other If Other, give details:  FORMTEXT       If incorporated, under which statute(s):  FORMCHECKBOX  Business Corporations Act  FORMCHECKBOX  Corporations Act  FORMCHECKBOX  Other If Other, state which statute(s):  FORMTEXT       c) When was the organization formed/incorporated? FORMTEXT       d) Check one of the following categories that best describes your Organization:  FORMCHECKBOX  Association FORMCHECKBOX  Cultural organization FORMCHECKBOX  Museum  FORMCHECKBOX  Benefit Trust FORMCHECKBOX  Educational Organization FORMCHECKBOX  Nursing Home/Home for Aged  FORMCHECKBOX  Chamber of Commerce FORMCHECKBOX  Fraternal Society FORMCHECKBOX  Religious Organization  FORMCHECKBOX  Charitable Organization FORMCHECKBOX  Foundation FORMCHECKBOX  Research/Development Institute  FORMCHECKBOX  Community Health Centre FORMCHECKBOX  Golf/Country Club FORMCHECKBOX  Social/Recreational club  FORMCHECKBOX  Community Service Organization FORMCHECKBOX  Healthcare Organization FORMCHECKBOX  Social Welfare organization  FORMCHECKBOX  Cooperative FORMCHECKBOX  Medical clinic FORMCHECKBOX  Trade Association FORMCHECKBOX  Other  specify:  FORMTEXT      e) Describe the function, purpose and general operations of the Organization? (Provide copies of information booklet if available): FORMTEXT       3. Does the Organization have any operations outside Canada?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf yes, give details:  FORMTEXT       4. Does the Organization have any direct or indirect subsidiaries, affiliates, associations or fraternities?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf yes, give details:  FORMTEXT      5. Does the Organization have any affiliated or subsidiary company operating for a profit?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf yes, give details:  FORMTEXT      6. Does the Organization have any stockholders or persons who profit from the operation  FORMCHECKBOX  Yes  FORMCHECKBOX  No except as salaried employees?If yes, give details:  FORMTEXT      7. Size of Operating Budget (Revenue + Cash Assets): $ FORMTEXT      8. Please indicate percentage of funds from the following sources: a) Federal, provincial, local government  FORMTEXT      %b) Dues from members  FORMTEXT      %c) Donations, contributions obtained from general public  FORMTEXT      %d) Fee(s) for service(s)  FORMTEXT      % e) Other:  FORMTEXT      %9. What percentage of the total funds received for the previous and current year was used for?a) Fund raising  FORMTEXT      %b) Administration  FORMTEXT      %c) Services  FORMTEXT      %d) Lobbying  FORMTEXT      %e) Labour negotiations  FORMTEXT      %10. a) Is the Organization tax exempt?  FORMCHECKBOX  Yes  FORMCHECKBOX  No b) Has the Organization filed a Federal Income Tax Return for any of the last five years?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Have the returns been accepted as filed?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf no, give details:  FORMTEXT      c) If the organization holds a charitable status, has this status ever been revoked or been  FORMCHECKBOX  Yes  FORMCHECKBOX  No subject to review?If yes, give details:  FORMTEXT      d) Is the organization in arrears in its payments of monies payable to Canada Customs and Revenue  FORMCHECKBOX  Yes  FORMCHECKBOX  No Agency or the provincial ministries of revenue?If yes, give details:  FORMTEXT      e) Is the organization currently or has it at any time during the past 5 years been in breach of any  FORMCHECKBOX  Yes  FORMCHECKBOX  No of its debt covenants, loan agreements or contractual obligations?If yes, give details:  FORMTEXT       11. a) Number of:Directors:  FORMTEXT       Officers:  FORMTEXT       Members:  FORMTEXT       (Schedule attached)Professional Employees state number, profession and whether part time or full time (attach separate sheet if necessary):  FORMTEXT      Clerical Employees: Full Time:  FORMTEXT       Part Time:  FORMTEXT       Volunteers:  FORMTEXT       Other:  FORMTEXT       Other, state number and description: FORMTEXT      b) Indicate number of unionized employees?  FORMTEXT      c) Indicate number of employees terminated voluntarily in the last 2 years?  FORMTEXT      d) Indicate number of employees terminated involuntarily in the last 2 years?  FORMTEXT       e) Indicate annual turnover rate of employees?  FORMTEXT      f) Have any layoffs or staff reductions taken place within the last 2 years or is any anticipated  FORMCHECKBOX  Yes  FORMCHECKBOX  No within the next two years?If yes, attach full details.g) Does the Organization have a full-time Human Resources manager or department?  FORMCHECKBOX  Yes  FORMCHECKBOX  Noh) Does the Organization have written Human Resources procedures to address  FORMCHECKBOX  Yes  FORMCHECKBOX  No compensation, performance appraisals and grievances?i) Does the Organization have policies to prohibit discrimination and harassment of all types?  FORMCHECKBOX  Yes  FORMCHECKBOX  Noj) Are written records kept of applications, performance related issues and exit interviews?  FORMCHECKBOX  Yes  FORMCHECKBOX  Nok) Does the Organization have an Employee Handbook?  FORMCHECKBOX  Yes  FORMCHECKBOX  No12. a) Does the Organization engage in any form of research, development, testing or experimentation?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf yes, attach full details.b) Does the Organization set standards for qualifications and performance of others or for the  FORMCHECKBOX  Yes  FORMCHECKBOX  No quality of products manufactured, sold, handled or distributed by others?If yes, attach full details.c) Is the Organization a licensing body for its members?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf yes, attach full details, including title of applicable legislation.d) Does the Organization take or recommend any disciplinary action as a result of peer review  FORMCHECKBOX  Yes  FORMCHECKBOX  No activities? If yes, attach full details.e) Does the Organization provide counseling services, legal aid services, healthcare services or  FORMCHECKBOX  Yes  FORMCHECKBOX  No any other professional services to its members or to the public?If yes, attach full details.f) Does the Organization publish any magazines, periodicals, newsletters or technical manuals?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf yes, attach full details.g) Does the Organization promote, sponsor or provide any form of insurance to its members or  FORMCHECKBOX  Yes  FORMCHECKBOX  No non-members?If yes, attach full details.h) Is the Organization directly involved in the promotion of any specific product or service to  FORMCHECKBOX  Yes  FORMCHECKBOX  No Organization members which will produce a profit for the Organization?If yes, attach full details.i) Does the Organization engage in lobbying, labour negotiations, collective bargaining or  FORMCHECKBOX  Yes  FORMCHECKBOX  No similar activities?If yes, attach full details. 13. a) Within the last five years, has the Organization received an enquiry, complaint or notice of  FORMCHECKBOX  Yes  FORMCHECKBOX  No hearing from any Provincial or Federal Regulatory Authority?If yes, give details:  FORMTEXT      b) Within the last five years, has the Organization received an enquiry, or complaint from any  FORMCHECKBOX  Yes  FORMCHECKBOX  No Provincial or Federal Tax Auditor?If yes, give details:  FORMTEXT      14. Has the Organization and/or its Directors, Officers, or any person(s) proposed for this insurance  FORMCHECKBOX  Yes  FORMCHECKBOX  No been involved in or have they any knowledge of pending Federal, Provincial or local legal actions or proceedings against the Organization and/or its Directors, Officers, or any person(s) proposed for this insurance: If yes, give details:  FORMTEXT      15. Within the scope of this proposed insurance:a) Has any claim been made, or is any claim now pending against the Organization or any person  FORMCHECKBOX  Yes  FORMCHECKBOX  No proposed for insurance?If yes, give details:  FORMTEXT      b) Has any Director, Officer or any person(s) proposed for insurance any knowledge or information  FORMCHECKBOX  Yes  FORMCHECKBOX  No of any  Wrongful Act ,  Outside Directorship Wrongful Act or  Employment Practices Wrongful Act which he or she should expect could give rise to a claim against him or her? If yes, give details:  FORMTEXT      16. Are any of the Directors, Officers, or any person(s) proposed for insurance indebted to the Organization?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf yes, give details:  FORMTEXT      17. Has any similar insurance on behalf of the Organization been declined, cancelled or renewal thereof refused?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf yes, give details:  FORMTEXT      18. Directors and Officers Liability Insurance or Association Liability Insurance carried during the past three years: InsurerLimit of LiabilityDeductiblePeriodPremium FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      19. 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6hnH tH CJOJQJ^JaJ.j:CJOJQJU^JaJhnH tH .jCJOJQJU^JaJhnH tH (jCJOJQJU^JaJhnH tH CJOJQJ^JaJhnH tH HHHH,J*j*j#Vy*jx$Ifckd$$Ifl4I**0*4 laf4 x$If^<<$If^ J"J$J,J.JZJ\JpJrJtJ~JJJJJdKfKhKKKKKKKKKKKKKLLLLLLLMMrMᬤzlCJOJQJaJhnH tH jUhnH tH jUhnH tH jUhnH tH @hnH tH @aJhnH tH  *CJjUhmHnHtH ujUhnH tH 6hnH tH CJ hnH tH jUhnH tH jUhnH tH ',J.JZJJ+*j*j x$If^<<$If^ckdb$$Ifl4**0*4 laf4JJKK#V*j/+ckd$$Ifl4**0*4 laf4x$Ifckdr$$Ifl4**0*4 laf4KKLLM*j*j#Vw*j x<$Ifckd$$Ifl4**0*4 laf4 x$If^<<$If^MMMNRNTNVN`NbNdNfNzN|N~NNNNNNNNNNNNNNNNNNNNNNOOOߝ߇q[*jCJOJQJUaJhnH tH *jCJOJQJUaJhnH tH *jCJOJQJUaJhnH tH *j'CJOJQJUaJhnH tH +jCJOJQJUaJhmHnHtH u*jCJOJQJUaJhnH tH CJOJQJaJhnH tH $jCJOJQJUaJhnH tH #6@6B6D6j6 88&8(8<8׳~pl^^M jCJOJQJUhnH tH 5CJOJQJhnH tH  *CJjUhmHnHtH ujT UhnH tH jUhnH tH 5hnH tH U hnH tH CJOJQJhnH tH CJOJQJaJhnH tH +jCJOJQJUaJhmHnHtH u$jCJOJQJUaJhnH tH *jCJOJQJUaJhnH tH equested:$ FORMTEXT       ACKNOWLEDGEMENTS:It is agreed that any claim arising from any  Wrongful Act which is known to any Director, Officer or any person(s) proposed for insurance prior to the issuance of the policy shall be excluded from coverage.Comments:  FORMTEXT        The undersigned authorized Officer of the Organization on behalf of the Directors and Officers and the Organization declares that to the best of his/her knowledge, after reasonable enquiry the statements set forth herein are true and complete. The Insurer is authorized to make any inquiry in connection with this Application. Signing this Application does not bind the Insurer to complete the Insurance. The information contained in and submitted with this Application is on file with the Insurer and along with the Application is considered physically attached to the Policy and will become part of it. The Insurer will have relied on this Application and attachments in issuing any Policy. This Application will become a part of such Policy if issued. If the information in this Application materially changes prior to the effective date of the Policy, the Applicant will notify the Insurer, who may modify or withdraw any quotation. I may have provided personal information in this document and by other means and I may in the future provide further personal information. Some of this personal information may include, but is not limited to, my credit information and claims history. I authorize my broker or insurance company to collect, use and disclose any of this personal information, subject to the law and to my broker s or insurance company s policy regarding personal information, for the purposes of communicating with me, assessing my application for insurance and underwriting my policies, renewals, changes of coverage, evaluating claims, detecting and preventing fraud, and analyzing business results. I confirm that all individuals whose personal information is contained in this document have authorized that I agree to the above on their behalf.Signature:Date: FORMTEXT      Capacity: FORMCHECKBOX  Chairman of the Board  FORMCHECKBOX  President  FORMCHECKBOX  Other FORMTEXT       One copy of the following is attached and made part of this proposal: 1. Last Annual Report or Audited Financial Statement 2. Charter or Bylaws Agent/Broker: FORMTEXT       THIS APPLICATION WILL BE CONSIDERED AS FORMING PART OF THE POLICY. Schedule of Directors and OfficersNamePresent Position in the OrganizationLength of Time as a Director/OfficerOccupationSalaried or Non-SalariedVoting or Non-Voting FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Salaried  FORMCHECKBOX  Non-salaried FORMCHECKBOX  Voting  FORMCHECKBOX  Non-voting FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Salaried  FORMCHECKBOX  Non-salaried FORMCHECKBOX  Voting  FORMCHECKBOX  Non-voting FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Salaried  FORMCHECKBOX  Non-salaried FORMCHECKBOX  Voting  FORMCHECKBOX  Non-voting FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Salaried  FORMCHECKBOX  Non-salaried FORMCHECKBOX  Voting  FORMCHECKBOX  Non-voting FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Salaried  FORMCHECKBOX  Non-salaried FORMCHECKBOX  Voting  FORMCHECKBOX  Non-voting FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Salaried  FORMCHECKBOX  Non-salaried FORMCHECKBOX  Voting  FORMCHECKBOX  Non-voting FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Salaried  FORMCHECKBOX  Non-salaried FORMCHECKBOX  Voting  FORMCHECKBOX  Non-voting FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Salaried  FORMCHECKBOX  Non-salaried FORMCHECKBOX  Voting  FORMCHECKBOX  Non-voting FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Salaried  FORMCHECKBOX  Non-salaried FORMCHECKBOX  Voting  FORMCHECKBOX  Non-voting FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Salaried  FORMCHECKBOX  Non-salaried FORMCHECKBOX  Voting  FORMCHECKBOX  Non-voting FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Salaried  FORMCHECKBOX  Non-salaried FORMCHECKBOX  Voting  FORMCHECKBOX  Non-voting FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Salaried  FORMCHECKBOX  Non-salaried FORMCHECKBOX  Voting  FORMCHECKBOX  Non-voting FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Salaried  FORMCHECKBOX  Non-salaried FORMCHECKBOX  Voting  FORMCHECKBOX  Non-voting FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Salaried  FORMCHECKBOX  Non-salaried FORMCHECKBOX  Voting  FORMCHECKBOX  Non-voting FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Salaried  FORMCHECKBOX  Non-salaried FORMCHECKBOX  Voting  FORMCHECKBOX  Non-voting FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Salaried  FORMCHECKBOX  Non-salaried FORMCHECKBOX  Voting  FORMCHECKBOX  Non-voting FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Salaried  FORMCHECKBOX  Non-salaried FORMCHECKBOX  Voting  FORMCHECKBOX  Non-voting FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Salaried  FORMCHECKBOX  Non-salaried FORMCHECKBOX  Voting  FORMCHECKBOX  Non-voting FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Salaried  FORMCHECKBOX  Non-salaried FORMCHECKBOX  Voting  FORMCHECKBOX  Non-voting FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Salaried  FORMCHECKBOX  Non-salaried FORMCHECKBOX  Voting  FORMCHECKBOX  Non-voting FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Salaried  FORMCHECKBOX  Non-salaried FORMCHECKBOX  Voting  FORMCHECKBOX  Non-voting 7707 (10/08) Central/Atlantic Region Page  PAGE 3 of  NUMPAGES 6 O66@6 *j+ *j<x$If^ckd$$Ifl4**0*4 laf4x$If@6B6D6h6j6 80*v:*jRiJ*jx$If@kdi $$Ifl** t644 la$Ifckd $$Ifl4**0*4 laf4 88$8&8N8P8R8{,*js+oma0* 9 $IfxBkdk $$Ifl)** t644 lax$If@kd $$Ifl** t644 la<8>8@8J8L8N8P8R8??0DnD:FP>??:F 90*j0*j0*j0*j0*j0*j0*^0*j xx$Ifnkdf $$Ifl*+   04 lap :FJhJjJ~JJJJJJJJJJJJJKKKKKK K*K,K.K0KDKFKHKRKTKVKXKlKnKpKzK|K~KK׾ jCJUj5Uj05Uj5Uj5UmHnHujD5U5 j5UCJOJQJhnH tH  hnH tH CJCJ#5CJfH hnH q tH 5fH hnH q tH 2IIII J>JjJJJJJJ 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