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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
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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- Spring '14