: i

't I
I
UMTED S
A BENKS'IIRE

Lraerlrv
COfiPA{Y

lNsuRANcE GRouF

uslLt.coM 884-523-5545

ors and OlTicers Lierbility and Employm nt Practices Liability

"THEANSWER"
All questionsmust be answeredand FOR A THIS IS AN APPLICATION Defensecosts shall be applied against tion must be signed by tho chairpersonof the boardor presjdentof the applicant.

Corporate Dir

MADEPOLICY. PLEASE READ'TOUR POLICY CAREFUT.LY

nltention.

General Infonnation Applicant's

address: Location
City:

zip: I Oat \

Webaddress: of address Primary E-mail of Description operations: Yearsestablished: Formof organization:

1. want any Doesthe apPlicant lf Yes, pleaselist

SCorporations O Partnership
O Other:

tr Cooperative

o vesSNo

2.

ls the applicanta subsidiaryof Name of

organization may be providedwith this information)

o Yesfruo

(A Information Premium Financial

Count Employee
Full time emPloYees time _ in: California greaterthan 10% OYesBNo Temporary/Seersonal _ Florida

Independent Contractors Louisiana

Leased

are Howmanyof theabove and Directors Officers that list 3. Please all shareholders

Outsidethe U.S.

OYestrNo

a 4. ls anyshareholdertrustthat of for securities the benefit

lf yes, pleaseexPlainfullY in an

as an EmployeeStock OwnershipPlan under EftlSA or holds lf "Yes", please attach most recentstock valuatkrnreport to this application.

B Yestr'No

CDAPP4/10

pag 1 of 4

A. Have there been anv

in the board of directorsor senior management the past in

for 3 years reason

B . Hastheapplicant

thanexpiration term,death iretiremenl? of or outside auditors thelast3 yaars? in an'1 material weaknqsses applicants in system internerl of controls c,rbreached debtcovenant, agreement othermaterial any loan or ?
months completedor agreedto, or does it contemplate lvithinthe

c. Havetheauditors
D. Hastheapplicant
obligationin the past 3

trYesONo trYestrNo BYesONo

BYesONo trYestrNo trYesONo OYesONo OYestrNo trYesONo trYesONo BYesONo BYesBNo

in 5. Hastheapplicant thepast next12months, ofthe any lf yes,please explain fully.

A. Merger,acquisition or B. Sales,distribution or for C. Any registration a D. Any privateplacement?

whther notsuchtransaclion or willbe completed? or are

with anotherentity? of more than 25% of assetsof stock of the organization? ,oifering?

E. Reorganization or
EmploymentPracticesLiability 6. Do more than 507oof all

anirngement creditors? with currently morethan$100,000? earn

ce downsized,laid off, or redu,ced staff in the past 12 monthsor was/will be affected?

proposed for 7. Hasanyentity

of lf "Yes,"what percentage the Wdtten GuidelineRequirements: A, Does each entity proposed place or is willing to B. Does each entity proposed policy anti-harassment

anticipatedoing so in the next 1 months?

policy insurance havea written in email/internet currently onewithin21 daysof bindingi) insurance havea written and Anti-Discrimination
in place or is willing to implernent one within21 days of binding??

D Ye,s No O B B Yers No

Fiduciary

Types plans: Health& welfare of Deline

DefineBenefit 8. Have any of the followingtaken

HWP

plarn= ESOP Employee stockownership

plan= DCP
CIBP

plan=EBP Excess benefit

Other:

to or beenagreed in the past3 yearsor areany please explain in an attachment. fully tf "Yes", OYestrNo OYesONo OYesBNo options to select fromat least3 investment El YesO No trYesBNo contributions?

in anticipated the next12 or deficiency B. Funding L

transfer assets, termination a Plan(s)? of of A. Merger, or of C. Formation acquisition plan? allowthe Doeseach401KPlan

the andto monitor Performance each selection?

advised 10. Are 401k participants the opportunityto adjust their 11, Does eachPlansubjectto of applicablerequirements the performanceof their investmentoptionsand given at least annually? (Eimployee Retirementlncome lSecurity Act) comply with all of and the lntemalRevenueCoder 1986,as amended(the'Code")

standards? ve,sting, responsibility funding liduciary and eligibility, including, thatthereareno violations anyplandocument of 12. Haseachplanbeenreviewed ensure transactions? and'Code' or of theERIEA please were explain an aftachment. in lf 'No'or if anyviolations
I

BYestrNo OYestrNo
page 2oI 4

CD APP 4iIO

the has 13. Within past1Bmonths, by morethan107o? Losslnformation the has 14. Within last5 years any
claim,suit,i discrimination or Applicant any individual 15. Withinthe last 5 years,has or againstthe applicant any or employeeof the applicant?

ilctuary found that any plan was or is cunentlyunder-funded

tr Ye'sO No
related,third party h;rrassment third party' or , complaintor notice of hearingbeen made againstthe for lnsurance? claim, suit inquiry,complaintor notice of hearingbeen made proposedfor lnsurancein the capacityof director,officer, 0 Yers No O

tr Yers No tr
fot this Insuranceaware of any fact, circumstance siltualion or the applicantor any of its directors,officers,or employees? completea UnitedStatesl,iability Insurance Groupclaimsupplement. claim been made or is any claimnow pending plan, against arny for this Insurancein the capaOity a fiduciary,trusteeor adminiskator? as for this insuranceaware of any fiact,circumstance, situ:rtion ERISA violation or

or 16. ls anyperson entity

which may result in a claim

O Yers No O

9, lf 'Yes'to question 10or 11,

17. Withinlhe past 5 years,has or organization individual lf 'Yes", pleaseexplain 18. ls any personor entity which may resuh in a claim that

O Yestr No

fall within scopeof the proposed the Insurance?

O Yes O No

explain lf 'Yes",please
New York Disclosure Notice: occurrencesor allegedwrongful thoseclaimsmadeagainstan i policy is written on a claims madr: basis and shall provicle coveragefor claims arisingout of incidents, no thrt took place prior to the retroarctive only date, if any, stated on the declarations. This policy shallrcover

extended for except the automatic

60 policyincludes automatic day an an additionalpremiuman additional PotentialcoveragegaPs may arise relationship,claims-maderatesare independentoverall rate increases

o1i whilethe policyremains effer;t all coverage upontermination thepolicy under policy the cea$es in and period period purchases The coverage. coverage extend reporting unless insured the additional
claims reportingperiod,following terminatio'n this policy. The Insuredmay purchase of the for of reportingperiod of 12 mronths, monthsor 3li monthsfollowingthe termination this policy. 24 the expirationfor this extendrldreportingperiod. Duringthe first several years of a claims-made parativelylowerthan occuffencerates. The insuredcan expect substantialannual premiumincreases

andArkansas Mlssouri
which means that "defensecosts" further legal "defensecosts" and liabilitY employmentPractices

the claims-made relationship matured. has provision within limits the Notlces: I understand acknowledge thispoliqy a and that contains defense for I Should occur, shallbe liable any that reduce limitsof insurance exhaust my themcompletely. and
to This provisionapplies to the directorsand officersliabilitycoveragepart and also appliesi the or ltart if I have more than 200 ernployees if my limits of liabilityare less than $500,000.

bY and Signed accepted the

Virginia Notice: You have an not elect this option,the limit ot

of or Signature President Chairperon

to purchasea separate limit of tiabilityfor the extensionperiod, Policy common conditionsl. lf you do for the extensionperiod shall be pari of the and not irr additionto limit specifiedin the declarations.

made or A madein the application in anyaffidavit shall deremed insured's the representations.statement in Statements theapplication proven suchstatem0nt was that it the unless is clearly will not be deemed or coverage material invalidate or before aftera lossunder to material the riskwhenassumed rvasunlrue. to or with is or authorization agreement bindtheinsurance" replaced "Authorization agreement bind to Notice: Theclause Minnesota
the insurancemay be withdrawnor the insuranceappliedfor that may insured prior to the effectivedate of nonpaymentof Premium. of based on changes to the informationcontainedin this applicationprior to the effectivedLate to with a minimumof 10 days noticegi'ven the inaccurate,untrue or incornpleteany statementmarde when the contract has been in effect for lesr; than 90 days or is being canceledfor

ColoradoFraudStatemenf lt is

to or nt for the purpose of defraudingor aftemptingto defraudthe policyholderor claimantwith regatrd a to information a PolicYholder of the proceeds within department from shallbe reported the Colorado to divis;ion insurance of or settlement awardPayable agencies. regulatory for of to information an insurer thepurpose falseor misleading Fraud WARNING:lt is a crimeto provide District of Golumbia if or Penaltiesinclude imprisonment and/orfines. In addition,an insurer may deny insurancelbenefits the defrauding insurer anyother related a <;laim was provided by the applicant. materially falseinformation

for the purposeof defraudingor damages,Any insurancecompany

company to provide facts or to knowingly false,incomplete, misleading or information an insurance and fines, of irnprisonment, denial insurance, civil to defraud company. the may P'enalties include
talse, incomplete,or misleadingfacts or agtentof an insurancecompanywho knowinglyprovidcls

to place coverage in thersurpluslines market. Superiorcoverage may be availablein the Florida Fraud Statement: You are Aot Guaranty with lnsurance underthe Florida Peusons insured surplus are by linescarriers notprotersted admitted marketand at a lesser insurer. obligationof an insolvent unlicernsed respectto any right of recoveryfor who knowinglyand with intent to defraudany insurrance company or other person files an application Kentucky Fraud Statement AnY fiilse informationor conceals,lor the purposeof misleading,informationconcerningany fact material for insurancecontaininganY i acl, which is a crime. a commits fraudulent thereto
CD APP4/IO page ot4 3

Maine and Washington Fraud company for the purposeof New Jersey Fraud Statement: Any

It is a crime to knowinglyprovidofalse, incomplerte misleadinginformation an insuretnce to or the company.Penaltiesmay includeimprisonment, firresor a denial of insurancebenefits.

policy is whoincludes falseor nnisleading on for any information an application an insurance and to subject criminal civil files whoknowingly withintent defraud insumnce and company otherperson an application or to any NewYork FraudStatement:Any or of information any falseinfomation, conceals the purpose misleading, for of for insurance statement claim lntaining materially or cornmits fraudulent to not any a insurance which a crime shallalsobe subject a civilpenalty to is anrd conceming factmaterial aot,
exceed five thousanddollarsand Ohio Fraud Statement: Any applicationor files a claim Oklahoma Fraud Statement: claim for the proceedsof an PennsylvaniaFraud Statement: or for application insurance concerningany fact materialthereto penalties. Tennesseeand Virginia Fraud of company for the PurPose stated value of the claim for each such violation. wfro,with intent to defraud or knr)wing that he is facilitatinga fraud againstan insurer,submitsan a false or deceptivestatementis guilty of insurance fraud. : Any person who knowingl'y, and with intentto injure, defraudor deceive any insurer,makesany policycontainingany false, incompleteor misleading informationis guilty of a felony. frersonwho knowinglyand wittr intentto defraudany insurancecompanyor other personfiles an information oJclaim containingany materiallyfalse information cronceals the purposeof misleading, for or a fraudulentinsurancear:t,which is a crime and subjectssuch personto criminaland civil to It is a crime to knowingly'provide false, incompleteor misleadinginformation an insurance the company. Penaltiesincluder imprisonment, fines and denial of insurancebenefits.

presents falseor fraudulent for (All claim a titates): Anyperson whoknowingly FraudStatement presents for insurance guilty is lossor benefio r knowingly payment a of in falseinformation an application
of a crimeand may be s
Signature: Broker's
Some states requirethat we have lf the primary addressof the require that we have the names and Name of AuthorizedAgent or Name and Address of your (lnsured's)Authorized Ag6nt or Broker. the list,ed item #1 is in the state of New York. lowa or Flonida, states of New York, lowa and Florida in of your (insured's)authodzedAgent or Broker.

to fines and confinement prison. in

Address:
Mail completeapplicationthrough /\gent or Broker to:

represents to that Theunderigned

that those particularsand frat any claim, incidentor event

and statementsset forth hereinare true and agree best of his/her knowledgeand belief the particulars

declares further Theundersigned to of by ar) material the aoceptance theriskassumed the Company.
untrue, place prior to the effectivedate of the insuranceapplired which may render inaccurate, for

made irnmediatelybe reportedin writing to the Companyand the Company may withdrawor modifyany anY or incomplete statement quotations and/or or agreementto bind the insurance. The signingof this Applicationdoes not bind the unrJersigned outstanding is the lo nor of bind the to purchase insurance, does review thisApplication the Company issuea policy. lt is understood Company' relying shall therewith, be the submitted any is issued.lt is agreed tlrisApplication, includirrg material in the that on thisApplication theevent should policy issued and it will be attachedand becomea part of the policy. a basisof the contract Signature: Applicant's Title: of the Boardor President) Date:

CDAPP4/10

page 4 ot 4