Checklist Directors and Officers Insurance

{{company_name}}

{{company_address}}

Phone: {{phone}}

Email: {{email}}

Website: {{website}}

Date of Checklist Completion:

{{date}}

Company Information

Legal Name of Company: {{legal_company_name}}

Trading Name (if different): {{trading_company_name}}

Company Registration Number: {{company_registration_number}}

Date of Incorporation: {{incorporation_date}}

Primary Business Activities: {{primary_business_activities}}

Number of Directors: {{number_of_directors}}

Number of Officers (excluding directors): {{number_of_officers}}

Annual Revenue (last financial year): {{annual_revenue}}

Total Assets (last financial year): {{total_assets}}

Existing Insurance Information (if any)

Current D&O Insurer: {{current_d_o_insurer}}

Policy Number: {{current_d_o_policy_number}}

Expiry Date: {{current_d_o_expiry_date}}

Limit of Indemnity: {{current_d_o_limit_of_indemnity}}

Self-Insured Retention (SIR) / Deductible: {{current_d_o_sir}}

Risk Profile and Governance

Are there any pending or threatened legal actions against the company or its directors/officers? (If yes, provide details): {{pending_legal_actions}}

Has the company or any director/officer been subject to regulatory investigation or inquiry in the last five years? (If yes, provide details): {{regulatory_investigation}}

Are there any significant changes anticipated in the company’s operations, ownership, or structure in the next 12 months? (e.g., mergers, acquisitions, IPOs): {{anticipated_changes}}

Does the company have an established corporate governance framework? (e.g., board committees, compliance policies): {{governance_framework}}

Are there any foreign operations or directors/officers based in foreign jurisdictions? (If yes, specify jurisdictions): {{foreign_operations}}

Desired Coverage Details

Proposed Limit of Indemnity: {{proposed_limit_of_indemnity}}

Proposed Self-Insured Retention (SIR) / Deductible: {{proposed_sir}}

Desired Policy PeriodStartDate: {{desired_policy_start_date}}

Desired Policy Period End Date: {{desired_policy_end_date}}

Specific areas of concern or risks to be highlighted to insurers: {{specific_risks}}

Documentation Required for Underwriting (Please attach)

- Latest Audited Financial Statements (last 2-3 years): {{attached_financial_statements}}

- Memorandum of Incorporation (MOI) / Articles of Association: {{attached_moi}}

- Annual Reports (if applicable): {{attached_annual_reports}}

- Resumes/CVs for all Directors and Key Officers: {{attached_cvs}}

- Organizational Chart: {{attached_org_chart}}

- Details of any past D&O claims or circumstances that could give rise to a claim: {{attached_claims_history}}

- Copy of current D&O policy wording (if applicable): {{attached_current_policy}}

Declaration

I/We declare that the information provided in this checklist and any attachments is true and accurate to the best of my/our knowledge and belief. I/We understand that any misrepresentation or omission may lead to the voidance of any insurance policy issued.

Name of Authorised Signatory: {{authorised_signatory_name}}

Title: {{authorised_signatory_title}}

Date: {{declaration_date}}

Signature: _________________________