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Unformatted text preview: business since _______________________ and is:
o Public o Private 7. Not-for-profit State of Incorporation: ___________ 8. o Nature of Applicant operations: 14-03-0715 (Ed. 07/2005) 1 of 7 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 II. SPECIFIC INFORMATION: 1. Please attach a copy of the following for every Applicant seeking coverage:
• The latest Annual Report, including audited financial statements;
All subsequent Quarterly Reports to Stockholders;
The most recent reports filed with the SEC on Form 10-K and all subsequent 10-Qs;
All reports filed with the SEC on Form 8-K or Schedule 13D (by any filer, with respect to any equity
securities of such Applicant) during the preceding twelve months;
The notice to shareholders and proxy statement and (if different) the most recent definitive proxy
statement filed with the SEC for both the last and next scheduled meetings;
The most recent CPA letters to management on internal controls, together with management’s
All Registration Statements of securities made in the last year; and
The latest Convention Statement, if applicable. 2.
3. Policy Period Requested:
From ________ to Retention Requested: $ Limit of Liability Requested: $ 4. both days at 12:01 a.m. at the principal address of the Parent Organization. Ownership:
o Stock o Mutual a. Type of ownership: b. If securities issued by any Applicant are publicly traded, provide the stock symbol for each such
Applicant and identify any exchange on which the securities are listed or traded: c. If the Parent Organization is privately held, provide the following:
Number of common shares outstanding: Number of common stockholders: d. Provide the name and ownership percentage of every direct or indirect beneficial owner of 5% or
more of the common shares of (i) the Parent Organization or (ii) any other Applicant whose
common shares are publicly traded: e. Has there been a change in controlling ownership (10% or more) in the last five
If “Yes”, attach details. o Yes o No Are there any negotiations now pending for the sale of stock in this Company in
excess of 10% of the total stock outstanding?
If “Yes”, attach details. o Yes o No f. g. Describe fully any securities convertible into common stock that have been issued by (i) the Parent
Organization or (ii) any other Applicant whose common shares are publicly traded: 14-03-0715 (Ed. 07/2005) 2 of 7 Financial Institution Portfolio SM Chubb Group of Insurance Companies
15 Mountain View Road
Warren, New Jersey 07059 5. Executive Liability and Entity Securities Liability Coverage
Non-Bank Application Provide the following information (attach details) for any Subsidiaries (including Subsidiaries of
Subsidiaries) newly acquired or created in the last 12 months: If none, please indicate.
a. Name ___________ f. Domestic or foreign...
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This document was uploaded on 03/30/2014.
- Spring '14