Monarch Insurance Brokers

LIABILITY INSURANCE FOR DIRECTORS & OFFICERS OF NON-PROFIT ORGANIZATIONS INSURANCE APPLICATION FORM

NOTE: Completion of this application form does not bind the Insurer to offer the insurance nor does it obligate the Applicant to purchase the insurance. This application is a declaration and shall form part of any policy wich may be issued.

Do not print this page! For blank forms click here. To submit it online, complete this page and select the "Finish" button at the bottom of the page

NOTE: If the spaced provided to answer any of the questions on this application are insufficient to fully answer the question, please use the remarks section at the end of the form. If it is a continuation from a particular question, please be sure to indicate which question.

1. GENERAL INFORMATION

a) Name of Applicant

b) Address

c) Email Address:

d) Website:

e) Describe the organization's legal structure (corporation, association, foundation, professional, trade, service, or charitable organization, etc.):

f) Describe the organization's objectives and type of activities:

g) Identify the Officer of the organization designated to receive in the name of the corporation or any subsidiary more than 50% owned, all notices from the Insurer concerning this insurance:
Name:
Title:

h) Incorporated as a non-profit organization,
on (date) , at (place):

Jurisdiction
Federal
Provincial

Conducted business continuously since:

Is the organization affiliated to or subsidiary of a Profit association or firm?
Yes
No
If "Yes", please specify:

THE ORGANIZATION

2. a) Total number of Employees

b) Total number of Members

c) Total number of Volunteers

d) Total number of Directors

e) Specify funding sources and their respective income in percentage (government, members, donations, etc.):
1. %
2. %
3. %
4. %

f) Percentage of the services provided or activities performed in:
Canada: %
United States: %
Other Country: %

g) For the current year, indicate: (estimate)
Income: $
Profits: $
Losses: $

h) What percentage of total income is used for charitable purposes?
%

3. Does the organization or any proposed person for the purpose of this insurance, perform the following?
(If Yes, please explain in the space provided.)

a) Promote, sponsor or provide any form of insurance to its members or non-members?
Yes
No

b) Promote any specific product to its members in return for a remuneration or commission?
Yes
No

c) Publish any magazines, periodicals or bulletins? (If yes, please forward to Monarch)
Yes
No

d) Publish a technical manual? (If yes, briefly describe its contents)
Yes
No

e) Engage in advertising, broadcasting or reproduction of copyright materials on behalf of itself or its members?
Yes
No

f) Engage in activities related to labour negotiations?
Yes
No

g) Evaluate through a peer review panel the qualifications and performance of others or the quality of products manufactured, sold, handled or distributed by others?
Yes
No

h) Take or recommend any disciplinary action as a result of peer group activities?
Yes
No

i) Provide referral, legal aid or information services to its members or to the public?
Yes
No

j) Engage in any form of research, development, experimentation or testing?
Yes
No

k) Provide loans to Directors and Officers or to organizations controlled by Directors and Officers? Are any of the Directors or Officers indebted to the association?
Yes
No

l) Provide any professional services to others? If yes, please list.
Yes
No

4. a) How frequently does the Board of Directors meet?

How many Board members must be present to constitute a quorum?

b) Describe the procedures in place to keep the Directors and Officers informed of new developments, operational results, etc. between meetings:

c) Describe the procedures in place to document decisions and important events?

5. Does a political party or a trade union sponsor the organization, or is it involved in the activities and operations of any political committee, trade union or federation?
Yes
No
If "Yes", please describe

6. Is the organization in arrears in its payments of monies payable to Canada Customs and Revenue Agency or the provincial ministries of revenue (including source deductions, G.S.T. and P.S.T.)? (If yes, please forward details to Monarch separately)
Yes
No

7. Has the organization, at any time over the past five (5) years, been in breach of any of its debt covenants, loan agreements, or contractual obligations?
Yes
No
If "Yes", please describe

CURRENT INSURANCE COVERAGE AND EXPERIENCE

TYPE OF INSURANCE	LIMIT OF POLICY	PERIOD OF INSURANCE	INSURER	DEDUCTIBLE
Directors' and Officers' Liability Insurance
General Liability Insurance
E & O Liability Insurance

Since what date has insurance been subscribed without interruption?

8. a) During the past five (5) years, has any insurance similar to that now proposed been declined, cancelled or has the renewal been refused to the Applicant by an Insurer?
Yes
No

b) During the past five (5) years, has any claim been made or is any claim now pending against the Applicant and/or any Director or Officer of the organization and/or any person proposed for this insurance?
Yes
No

c) Is the undersigned or any other person proposed for this insurance aware of any facts or circumstances involving the organization, its subsidiaries or the Directors and Officers of the trustee, employees, volunteers, or committee members of the organization or its subsidiaries, which he/she has reason to believe might result in any future claim?
Yes
No

If "Yes" to 'a', 'b', or 'c', please give details: (Forward additional info to Monarch, if needed)

WITHOUT LIMITATION TO ANY OTHER REMEDY AVAILABLE TO THE INSURERS, THE PROPOSED INSURANCE WILL NOT AFFORD COVERAGE TO ANY CLAIMS OF WHICH ANY PERSON PROPOSED FOR THIS INSURANCE HAS KNOWLEDGE NOR ANY CLAIMS RESULTING FROM ANY FACTS OR CIRCUMSTANCES OF WHICH ANY PERSON PROPOSED FOR THIS INSURANCE HAS KNOWLEDGE.

d) REQUESTED LIMIT OF LIABILITY:
$250,000 per claim / $250,000 per policy period
$500,000 per claim / $500,000 per policy period
$1,000,000 per claim / $1,000,000 per policy period
Other limit required:

e) AMOUNT OF DEDUCTIBLE:
$0
$1,000
$2,500
$5,000
Other deductible required:

SCHEDULE OF ADMINISTRATORS AND OFFICERS (fill in as many rows as needed)

NAME	RESPONSIBILITIES AND DUITES WITHIN THE ORGANIZATION	EXPERIENCE AS ADMINISTRATOR	OFFICIAL POSITION	REMUNERATED
				Yes No
				Yes No
				Yes No
				Yes No
				Yes No
				Yes No
				Yes No
				Yes No
				Yes No
				Yes No
				Yes No
				Yes No
				Yes No
				Yes No
				Yes No
				Yes No
				Yes No
				Yes No
				Yes No
				Yes No
				Yes No
				Yes No
				Yes No
				Yes No
				Yes No

REMARKS (optional - or use to complete questions above)