Chubb Group of Insurance Companies 15 Mountain View Road Warren, New Jersey 07059Financial Institution Portfolio SMExecutive Liability and Entity Securities Liability Coverage Non-Bank Application14-03-0715 (Ed. 07/2005) 1 of 7 BY COMPLETING THIS APPLICATION YOU ARE APPLYING FOR COVERAGE WITH FEDERAL INSURANCE COMPANY (THE “COMPANY”) NOTICE: THE EXECUTIVE LIABILITY AND ENTITY SECURITIES LIABILITY COVERAGE SECTION PROVIDES CLAIMS MADE COVERAGE, WHICH APPLIES ONLY TO "CLAIMS" FIRST MADE DURING THE "POLICY PERIOD" OR AN APPLICABLE EXTENDED REPORTING PERIOD. THE APPLICABLE LIMIT(S) OF LIABILITY TO PAY DAMAGES OR SETTLEMENTS WILL BE REDUCED AND MAY BE EXHAUSTED BY "DEFENSE COSTS" AND "DEFENSE COSTS" WILL BE APPLIED AGAINST THE RETENTION AMOUNT. IN NO EVENT WILL THE COMPANY BE LIABLE FOR “DEFENSE COSTS” OR THE AMOUNT OF ANY JUDGMENT OR SETTLEMENT IN EXCESS OF THE APPLICABLE LIMIT(S) OF LIABILITY. READ THE ENTIRE APPLICATION CAREFULLY BEFORE SIGNING. APPLICATION INSTRUCTIONS: 1. Whenever used in this Application, the term "Applicant"shall mean the Parent Organization and all organizations applying for coverage. 2. Include all requested underwriting information and attachments. Provide a complete response to all questions and attach additional pages if necessary. I. GENERAL INFORMATION: 1. Name of Applicant: 2. Address of Applicant: City: ___________________State: __________ Zip Code: ___________Telephone: 3. Web address: 4. Name and Title of Primary Contact: Primary Contact: Officer designated, as agent of the Company and of all insured Directors and Officers, to receive any an all notices from the Insurer or their authorized representative(s) concerning this insurance. 5. Address of Primary Contact: City: _____________ State: __________Zip Code: ___________Telephone: 6. The Applicanthas continuously been in business since _______________________and is: oPublic oPrivate oNot-for-profit 7. State of Incorporation: ___________ 8. Nature of Applicantoperations:
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