SUPPLEMENTAL APPLICATION

Transcription

1 Chubb Group of Insurance Companies 15 Mountain View Road, Warren, New Jersey SUPPLEMENTAL APPLICATION BANKERS PROFESSIONAL LIABILITY POLICY INVESTMENT BANKING UNDERWRITTEN IN FEDERAL INSURANCE COMPANY OR VIGILANT INSURANCE COMPANY BANKERS PROFESSIONAL LIABILITY COVERAGEE IS WRITTEN ON A CLAIMS-MADE BASIS. EXCEPT ASS OTHERWISE PROVIDED, THIS POLICY WILL COVER ONLY CLAIMS FIRST MADE AGAINST THE INSUREDD DURING THE POLICY PERIOD. PLEASE READ THE POLICY CAREFULLY. DEFENSE COST PROVISION: PLEASE TE THAT THE DEFENSE COST PROVISION OF THIS POLICY STIPULATES THAT THE LIMITS OFF LIABILITY ARE REDUCED OR EXHAUSTED BY THE DEFENSE COSTS. ANY DEDUCTIBLE AMOUNT ISS REDUCED OR EXHAUSTED BY DEFENSEE COSTS. A. GENERAL INFORMATION Name of Applicant Name of Agent and Agent s License Number: Year servicee established or purchased: Total Number of Investment Banking Staff: a. Underwriters b. Analysts c. Consultants d. Traders e. Compliance f. All Other Employees Total Number of Offices from which the Applicant transacts Investment Banking business: Total Investment Banking Revenue for last two (2) years: $ $ 7. Is the Applicant ever an adviser on mergers and acquisitions? 8. Does the Applicant ever provide fairness opinions relative to mergers, acquisitions or divestments? 9. Does the Applicant have Section 20 powers? If no, are you filing for, or in the next 18 months do you anticipate filing for approval of Section 20 powers? 10. Does the Applicant have Tier II underwriting powers? If no, are you filing for, or in the next 18 months do you anticipate filing for approval for Tier II powers? Form (08/2012) Page 1 of 5

2 11. Regarding Underwriting, please fill in the blank regarding the following lines of business: LINE OF BUSINESS PERCENT OF REVENUE LARGEST ISSUE a. Equity $ b. Municipal Bond: (1) General Obligation $ (2) Revenue $ c. Corporate Debt $ d. Asset Backed $ 12. What individual(s) and/or committee reviews each underwriting? 13. What is the Applicant s industry underwriting expertise? Financial Services? Technology? Manufacturing? Healthcare? Biotech? Communications? Publishing? Retail? Broadcasting? Other? Does the Applicant expect any material change(s) in the list above within the next 18 months? If yes, please explain on a separate sheet. Page 2 of 5

3 14. Does the Applicant solicit business only from the Applicant s customers? a. If no, please describe, on a separate sheet, the Applicant s marketing strategies (i.e., direct mail, advertising, etc.). b. Identify, on a separate sheet, the states in which Investment Banking business is solicited. 15. a. Do clients sign a written Investment Banking contract or engagement letter with the Applicant? N O b. Does the contract/letter contain an arbitration agreement? N O c. Please provide a copy of a standard contract/letter. The undersigned persons declare that to the best of their knowledge the statements set forth herein in all sections of the Application and in any attachments to this SUPPLEMENTAL APPLICATION are true and correct, and that every reasonable effort has been made to obtain sufficient information from all persons proposed for this insurance to facilitate the proper and accurate completion of this SUPPLEMENTAL APPLICATION. The undersigned further agree that, if between the date of this SUPPLEMENTAL APPLICATION and the effective date of this Policy (1) any material change in the condition of the Applicant is discovered or (2) there is any material change in the answers to the questions contained herein, either of which would render this SUPPLEMENTAL APPLICATION inaccurate or incomplete, notice of such change will be reported in writing to the Insurer immediately, and, if necessary, any outstanding quotation may be modified or withdrawn. The signing of this SUPPLEMENTAL APPLICATION does not bind the undersigned on behalf of the Applicant to purchase the insurance, but it is agreed by the Applicant and all persons proposed for this insurance that the particulars and statements contained in this SUPPLEMENTAL APPLICATION and the attachments and materials submitted with this SUPPLEMENTAL APPLICATION (which shall be retained on file by the Company and shall be deemed attached to the Policy, if insurance is provided, as if physically attached thereto) are true and correct and will be the basis of the Policy and will be considered as incorporated in and constituting a part of the Policy. It is further agreed by the Applicant, and all persons proposed for this insurance, that such particulars and statements are material to the decision to provide this insurance and that any Policy will be issued in reliance upon the truth of such particulars and statements. PLEASE TE: ONLY DULY APPOINTED AGENTS OF THE COMPANY AND LICENSED BROKERS ARE AUTHORIZED TO SOLICIT APPLICATIONS FOR COVERAGE. AGENTS AND BROKERS ARE T AUTHORIZED TO BIND COVERAGE. COVERAGE SHALL BE PROVIDED UNLESS THE COMPANY ACCEPTS THE APPLICATION AND BINDS THE COVERAGE. False Information: Any person who, knowingly and with 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. Notice to Arkansas, Minnesota, New Mexico and Ohio Applicants: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false, fraudulent or deceptive statement is, or may be found to be, guilty of insurance fraud, which is a crime, and may be subject to civil fines and criminal penalties. Notice to Colorado Applicants: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory agencies. Form (08/2012) Page 3 of 5

4 Notice to District of Columbia Applicants: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits, if false information materially related to a claim was provided by the applicant. Notice to Florida Applicants: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. Notice to Kentucky Applicants: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. Notice to Louisiana and Rhode Island Applicants: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Notice to Maine, Tennessee, Virginia and Washington Applicants: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. Notice to Alabama and Maryland Applicants: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Notice to New Jersey Applicants: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Notice to Oklahoma Applicants: Any person who, knowingly and with intent to injure, defraud or deceive any employer or employee, insurance company, or self-insured program, files a statement of claim containing any false or misleading information is guilty of a felony. Notice to Oregon and Texas Applicants: Any person who makes an intentional misstatement that is material to the risk may be found guilty of insurance fraud by a court of law. Notice to Pennsylvania Applicants: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Notice to Puerto Rico Applicants: Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation with the penalty of a fine of not less than five thousand (5,000) dollars and not more than ten thousand (10,000) dollars, or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances are present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years. Notice to New York Applicants: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to: a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Company Page 4 of 5

5 Signature of Chief Executive Officer (or other Senior Officer if the Chief Executive Officer is also the Chairman, Board of Directors) Signature of Chairman, Board of Directors A policy cannot be issued unless the SUPPLEMENTAL APPLICATION is properly signed and dated by the Chief Executive Officer (or other Senior Officer if the Chief Executive Officer is also the Chairman, Board of Directors) and the Chairman, Board of Directors. Note: This SUPPLEMENTALPPLICATION and all exhibits shall be treated in strictest confidence. Date Form (08/2012) Page 5 of 5