OUTSIDE DIRECTORSHIP LIABILITY 15 Mountain View Road, Warren, New Jersey COVERAGE SECTION

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1 CHUBB APPLICATION Chubb Group of Insurance Companies OUTSIDE DIRECTORSHIP LIABILITY 15 Mountain View Road, Warren, New Jersey COVERAGE SECTION UNDERWRITTEN IN FEDERAL INSURANCE COMPANY, TEXAS PACIFIC INDEMNITY COMPANY, OR PACIFIC INDEMNITY COMPANY Outside Directorship Liability Coverage is written on a claims-made basis. Except as otherwise provided, this section of the policy will cover only claims first made against the Insured during the Policy Period. Please read the policy carefully. Defense Cost Provision: Please note that the Defense Cost provision of this policy stipulates that the Limits of Liability may be completely exhausted by the cost of legal defense. Any deductible may be similarly reduced or exhausted by Defense Costs. 1. GENERAL INFORMATION Parent Organization Address State of Incorporation Date Established 2. MATERIAL CHANGE Signing of this application does not bind the Parent Organization or the Company. If there is any material change in the answers to the questions prior to the policy inception date the Parent Organization will notify the Company in writing and any outstanding quotation may be modified or withdrawn. 3. UNDERWRITING INFORMATION As part of this application, please attach the following (where applicable): Completed Appendix A for any individual requesting coverage on any for-profit. Latest audited annual financial statement for any privately owned for-profit. 4. COVERAGE REQUESTED Outside Directorship Liability Limit requested $ 5. POLICY PERIOD REQUESTED From Organization. to both days at 12:Ol a.m. at the principal address of the Parent Form (Ed. 9-92) Page 1 of 6

2 6. SUBSIDIARIES information: nature of business, % owned, date acquired or created. 7. PARTNERSHIPS Does the Parent Organization, a subsidiary or any director or officer presently act in the capacity of general partner 8. OUTSIDE ENTITY INFORMATION If coverage is requested for any that qualifies as an exempt non-profit corporation, as described in Section 501(c)(3) of the Internal Revenue Code of 1986, please check the box: 501(c)(3) coverage requested. If coverage is requested for any Non-Profit other than those described above or any for-profit Outside Entity (excluding financial institutions), please complete and return Appendix A, Outside Directorship Liability Coverage Application Supplement. If coverage is requested for any that is a financial institution, please use Appendix B, Outside Directorship Liability Coverage Application Supplement for Financial Institutions. 9. FALSE INFORMATION Any person who, knowingly and with the intent to defraud any insurance company or other person, files an application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime. 10. DECLARATION AND SIGNATURE The undersigned declares that to the best of his or her knowledge and belief the statements set forth herein are true. Although the signing of this application does not bind the undersigned on behalf of the Parent Organization or its directors, officers or Insured Persons to effect insurance, the undersigned agrees that this application and its attachments shall be the basis of the contract should a policy be issued and shall be deemed attached to and shall form part of the policy. The Company is hereby authorized to make any investigation and inquiry in connection with this application that it deems necessary. This section of the application must be signed by the Risk Manager or other person responsible for purchasing insurance. Date Signature Title Page 2 of 6

3 OUTSIDE DIRECTORSHIP LIABILITY COVERAGE APPLICATION SUPPLEMENT APPENDIX A Name of Individual: Title: Location: Form (Ed 9-92) Page 3 of 6

4 Has or its D&OS been involved in any D&O litigation? Does maintain D&O Insurance? Yes No. If yes, provide details: Page 4 of 6

5 OUTSIDE DIRECTORSHIP LIABILITY COVERAGE APPLICATION SUPPLEMENT FOR FINANCIAL INSTITUTIONS APPENDIX B Outside Directorship Liability Coverage is written on a claims-made basis. Except as otherwise provided, this section of the policy will cover only claims first made against the Insured during the Policy Period. Please read the policy carefully. Defense Cost Provision: Please note that the Defense Cost provision of this policy stipulates that the Limits of Liability may be completely exhausted by the cost of legal defense. Any deductible may be similarly reduced or exhausted by Defense Costs. 1. UNDERWRITING INFORMATION As part of this application, please attach the following for each which is a financial institution. Latest annual report and audited financial statements. Notice to Stockholders and Proxy statements for the next scheduled meeting. Latest 10-K and 10-Q filed with S.E.C. Most recent Uniform Bank Performance Report(U.B.P.R.). Latest Annual F.H.L.B.B. Report for each savings and loan association. 2. OUTSIDE ENTITY INFORMATION Name of individual requesting coverage Name and address of Type of financial institution: Commercial bank Savings and loan Common Stock: Number of shareholders Number of shares outstanding Number of shares owned directly or beneficially by directors and officers Name and percentage owned of any shareholder holding directly or beneficially 5% or more of the common stock. (If none, so state.) Form (Ed. 9-92) Page 5 of 6

6 Has the publicly disclosed that it presently has under consideration any acquisitions, tender offers or mergers? Yes No. If yes, attach details. Does the provide indemnification for its directors and officers? Yes No. If yes, attach a copy. Have there been, during the last 5 years, or are there now pending any claims against this? Yes 0 No. If yes, attach details. 3. PRIOR KNOWLEDGE/REPRESENTATION It is important that you fill in the blank in this paragraph. I am unaware of any facts or circumstances which I have reason to suppose might give rise to a future claim that would fall within the scope of the proposed coverage, except: (If no exceptions please state.) It is agreed that if such facts or circumstances exist, whether or not disclosed, any claim arising from them is excluded from this proposed coverage. 4. FALSE INFORMATION Any person who, knowingly and with the intent to defraud any insurance company or other person, files an application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime. 5. DECLARATION AND SIGNATURE The undersigned declares that to the best of his or her knowledge and belief the statements set forth herein are true. Although the signing of this application does not bind the undersigned on behalf of the Parent Organization or its directors, officers or Insured Persons to effect insurance, the undersigned agrees that this application and its attachments shall be the basis of the contract should a policy be issued and shall be deemed attached to and shall form part of the policy. The Company is hereby authorized to make any investigation and inquiry in connection with this application that it deems necessary. This section of the application must be signed by the individual proposed for coverage. Date Signature Title Page 6 of 6