Chubb FI Folio New line app

Not for profit state of incorporation 8 o nature

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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 response; 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 (5) years? 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. o None a. Name ___________ f. Domestic or foreign...
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This document was uploaded on 03/30/2014.

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