Chubb FI Folio New line app

Name of parent institution c h total

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Unformatted text preview: ___________ b. Date created or acquired ___________ g. Name of parent institution ___________ c. ___________ h. Total revenues* ___________ d. Percent of ownership ___________ i. Total assets* ___________ e. Nature of business 6. State of Incorporation ___________ j. Net income* ___________ *most recent year end figures Provide the following information for the Applicant: Number of Directors 7. Number of Officers Recent, Pending and Contemplated Changes: a. Whether or not such discussions have been publicly disclosed, is any Applicant or any individual or entity proposed for coverage anticipating or currently involved in discussions with any other party concerning any actual or potential: o Yes o No (i) (ii) c Public offering of securities (whether or not such securities are required to be registered under the Securities Act of 1933 or any other similar Federal, State or Municipal Statute or qualification of securities under Regulation A or any other similar Federal, State, or Municipal Regulation)? o Yes o No If “Yes”, attach details, including the prospectus. (iii) b. Merger, acquisition, divestment, or tender offer? If “Yes”, attach details. Reorganization or material change in any arrangement with lenders, bond-holders, financiers or other significant creditors? If “Yes”, attach details. o Yes o No Has any regulatory agency denied or indicated that they would deny any contemplated merger, acquisition, or divestment in the last five (5) years? If “Yes”, attach details. o Yes o No Has any Applicant replaced its outside auditors at any time during the last 3 years? If “Yes”, attach details. o Yes o No d. Does any Applicant currently anticipate replacing its outside auditors? If “Yes”, attach details. e. Has the president, chief executive officer, chief financial officer or any executive vice president of any Applicant left such office within the last three (3) years for any reason other than death or retirement at normal retirement age? If “Yes”, attach details. 14-03-0715 (Ed. 07/2005) 3 of 7 o Yes o No o Yes o No Financial Institution Portfolio SM Chubb Group of Insurance Companies Executive Liability and Entity Securities Liability Coverage Non-Bank Application 15 Mountain View Road Warren, New Jersey 07059 8. Past Activities/Lawsuits/Proceedings: a. During the last 5 years, has any Applicant or any individual or entity proposed for coverage, in any capacity, been involved in any of the following matters or have any knowledge of any fact, circumstance, situation, transaction, event, act, error or omission or involving the following which may give rise to a claim under the proposed insurance? (i) o Yes o No (ii) Civil, criminal or administrative proceeding or formal or informal investigation concerning compliance or noncompliance with any federal or state securities law or regulation? o Yes o No (iii) Any other criminal action or proceeding? o Yes o No (iv) b. Antitrust, copyright or patent litigation? Class action, derivative suit...
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