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Financial Statements of the Institution
Investment Activities (Purchase, Sales, Gains & Losses)
Threatened or Actual Litigation 14-03-0715 (Ed. 07/2005) 5 of 7 No
No Financial Institution Portfolio SM Chubb Group of Insurance Companies
15 Mountain View Road
Warren, New Jersey 07059 Executive Liability and Entity Securities Liability Coverage
Non-Bank Application III. REPRESENTATION: PRIOR KNOWLEDGE OF ACTS/CIRCUMSTANCES/SITUATIONS: 1. Neither the Applicant nor any person or entity proposed for coverage is aware of any fact, circumstance,
or situation which he or she has reason to suppose might give rise to any claim that would fall within the
scope of the proposed coverage, except as follows:
(If the answer is none, so state): W ithout prejudice to any other rights and remedies of the Company, the Applicant understands and
agrees that if any such fact, circumstance, or situation exists, whether or not disclosed in response to
Question 1 above, any claim or action arising from such fact, circumstance, or situation, is excluded from
coverage under the proposed policy, if issued by the Company. IV. MATERIAL CHANGE: If there is any material change in the answers to the questions in this Application before the policy inception
date, the Applicant must immediately notify the Company in writing, and any outstanding quotation may be
modified or withdrawn. V. DECLARATIONS, FRAUD WARNINGS AND SIGNATURES The Applicant's submission of this Application does not obligate the Company to issue, or the Applicant to
purchase, a policy. The Applicant will be advised if the Application for coverage is accepted. The Applicant
hereby authorizes the Company to make any inquiry in connection with this Application.
The undersigned authorized agents of the person(s) and entity(ies) proposed for this insurance declare that to
the best of their knowledge and belief, after reasonable inquiry, the statements made in this Application and in
any attachments or other documents submitted with this Application are true and complete. The undersigned
agree that this Application and such attachments and other documents shall be the basis of the insurance policy
should a policy providing the requested coverage be issued; that all such materials shall be deemed to be
attached to and shall form a part of any such policy; and that the Company will have relied on all such materials
in issuing any such policy.
The information requested in this Application is for underwriting purposes only and does not constitute notice to
the Company under any policy of a Claim or potential Claim.
Notice to Arkansas, Louisiana, Maryland, 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.
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This document was uploaded on 03/30/2014.
- Spring '14