ACORD 807 Instructions


ACORD 807 (2009/02) rev. 02-27-2009 1 of 18

Section Name Field Name Field and/or Section Description
TITLE ACORD 807 (2009/02) Directors & Officers Liability Application The title of the form. ACORD 807, Directors and Officers Liability, form is used to apply for Directors and Officers liability coverage. The form may be used as a stand-alone application, or it may be used in conjunction with ACORD 825 – Professional / Specialty Insurance Application, when other professional or specialty coverages are being applied for.
IDENTIFICATION SECTION Agency Customer ID Enter identifier: The customer’s identification number assigned by the producer (e.g. agency or brokerage).
IDENTIFICATION SECTION Date Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY)
IDENTIFICATION SECTION Agency Enter text: The full name of the producer/agency.
IDENTIFICATION SECTION First Named Insured Enter text: The named insured(s) as it/they will appear on the policy declarations page. As used here, this is the first named insured.
IDENTIFICATION SECTION Policy Number Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license orcontract number.
IDENTIFICATION SECTION Carrier Enter text: The insurer’s full legal company name(s) as found in thefile copy of the policy. Use the actual name of the company within the group to which the policy has been issued. This is not the insurer’s group name or trade name.
IDENTIFICATION SECTION NAIC Code Enter code: The identification code assigned to the insurer by the NAIC.
IDENTIFICATION SECTION Requested Effective Date Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence.
IDENTIFICATION SECTION Expiration Date Enter date: The date on which the terms and conditions of the policy will expire.
COVERAGES Primary Check the box (if applicable): Indicates the directors and officers coverage is primary.
COVERAGES Excess Check the box (if applicable): Indicates the directors and officers coverage is excess.
COVERAGES Requested Limits Per Claim Enter limit: The requested per claim limit amount for directors and officers coverage.
COVERAGES Requested Limits Aggregate Enter limit: The requested aggregate limit amount for directors and officers coverage.
COVERAGES Current Limits Per Claim Enter limit: The current per claim limit amount for directors and officers coverage.
COVERAGES Current Limits Aggregate Enter limit: The current aggregate limit amount for directors and officers coverage.
COVERAGES Requested Retention Enter amount: The requested retention amount for directors and officers coverage.
COVERAGES Current Retention Enter amount: The current retention amount for directors and officers coverage.
ACORD 807 (2009/02) rev. 02-27-2009 2 of 18

Section Name Field Name Field and/or Section Description
COVERAGES Primary Check the box (if applicable): Indicates the company reimbursement coverage is primary.
COVERAGES Excess Check the box (if applicable): Indicates the company reimbursement coverage is excess.
COVERAGES Requested Limits Per Claim Enter limit: The requested per claim limit amount for company reimbursement coverage.
COVERAGES Requested Limits Aggregate Enter limit: The requested aggregate limit amount for company reimbursement coverage.
COVERAGES Current Limits Per Claim Enter limit: The current per claim limit amount for company reimbursement coverage.
COVERAGES Current Limits Aggregate Enter limit: The current aggregate limit amount for company reimbursement coverage.
COVERAGES Requested Retention Enter amount: The requested retention amount for company reimbursement coverage.
COVERAGES Current Retention Enter amount: The current retention amount for company reimbursement coverage.
COVERAGES Primary Check the box (if applicable): Indicates the company/entity liability coverage is primary.
COVERAGES Excess Check the box (if applicable): Indicates the company/entity liability coverage is excess.
COVERAGES Requested Limits Per Claim Enter limit: The requested per claim limit amount for company/entity liability coverage.
COVERAGES Requested Limits Aggregate Enter limit: The requested aggregate limit amount for company/entity liability coverage.
COVERAGES Current Limits Per Claim Enter limit: The current per claim limit amount for company/entity liability coverage.
COVERAGES Current Limits Aggregate Enter limit: The current aggregate limit amount for company/entity liability coverage.
COVERAGES Requested Retention Enter amount: The requested retention amount for company/entity liability coverage.
COVERAGES Current Retention Enter amount: The current retention amount for company/entity liability coverage.
COVERAGES Other Coverages Enter text: The description of the coverage.
COVERAGES Primary Check the box (if applicable): Indicates the coverage is primary.
COVERAGES Excess Check the box (if applicable): Indicates the coverage is excess.
COVERAGES Requested Limits Per Claim Enter limit: The requested per claim limit amount for the coverage.
COVERAGES Requested Limits Aggregate Enter limit: The requested aggregate limit amount for the coverage.
COVERAGES Current Limits Per Claim Enter limit: The current per claim limit amount for the coverage.
COVERAGES Current Limits Aggregate Enter limit: The current aggregate limit amount for the coverage.
COVERAGES Requested Retention Enter amount: The requested retention amount for the coverage.
COVERAGES Current Retention Enter amount: The current retention amount for the coverage.
ACORD 807 (2009/02) rev. 02-27-2009 3 of 18

Section Name Field Name Field and/or Section Description
COVERAGES Other Coverages Enter text: The description of the coverage.
COVERAGES Primary Check the box (if applicable): Indicates the coverage is primary.
COVERAGES Excess Check the box (if applicable): Indicates the coverage is excess.
COVERAGES Requested Limits Per Claim Enter limit: The requested per claim limit amount for the coverage.
COVERAGES Requested Limits Aggregate Enter limit: The requested aggregate limit amount for the coverage.
COVERAGES Current Limits Per Claim Enter limit: The current per claim limit amount for the coverage.
COVERAGES Current Limits Aggregate Enter limit: The current aggregate limit amount for the coverage.
COVERAGES Requested Retention Enter amount: The requested retention amount for the coverage.
COVERAGES Current Retention Enter amount: The current retention amount for the coverage.
COVERAGES Yes/No Separate Defense Costs Limits Enter Y for a “Yes” response. Input N for “No” response. Indicates if there is a separate defense costs limit for the coverage.
COVERAGES Separate Defense Costs Limits Enter amount: The limit amount for separate defense costs.
COVERAGES Defense Limit – Inside Check the box (if applicable): Indicates the defense limit is inside.
COVERAGES Defense Limit – Outside Check the box (if applicable): Indicates the defense limit is outside.
COVERAGES Pending & Prior Litigation Date Enter date: The pending and prior litigation date.
SHARED LIMITS Shared Limits Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Are there Shared Limits?”.
SHARED LIMITS Additional Coverages Attached Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Additional coverages attached?”.
SHARED LIMITS EPLI Check the box (if applicable): Indicates the Employment PracticesLiability Insurance (EPLI) section is attached to this policy.
SHARED LIMITS Professional Liability Check the box (if applicable): Indicates the Professional Liability section is attached to the policy.
SHARED LIMITS Crime Check the box (if applicable): Indicates the Crime or Miscellaneous Crime section is attached to this policy.
SHARED LIMITS Fiduciary Check the box (if applicable): Indicates the Fiduciary section is attached to the policy.
SHARED LIMITS Other Check the box (if applicable): Indicates that a section that is not listed specifically on the form is attached to this policy.
SHARED LIMITS Other Description Enter text: The type of section being attached to the policy.
SHARED LIMITS Other Check the box (if applicable): Indicates that a section that is not listed specifically on the form is attached to this policy.
SHARED LIMITS Other Description Enter text: The type of section being attached to the policy.
ENDORSEMENTS World Wide Coverage Check the box (if applicable): Indicates the world wide coverage endorsement applies.
ENDORSEMENTS Form Number Enter identifier: The number used by the insurer for this form.
ACORD 807 (2009/02) rev. 02-27-2009 4 of 18

Section Name Field Name Field and/or Section Description
ENDORSEMENTS Title Enter text: The name of the form.
ENDORSEMENTS Edition Date Enter date: The edition date of the form.
ENDORSEMENTS Duly Constituted Committee Charge Check the box (if applicable): Indicates the duly constituted committee charge endorsement applies.
ENDORSEMENTS Form Number Enter identifier: The number used by the insurer for this form.
ENDORSEMENTS Title Enter text: The name of the form.
ENDORSEMENTS Edition Date Enter date: The edition date of the form.
ENDORSEMENTS ODL-Non Profit Check the box (if applicable): Indicates the outside directorship liability (ODL) non profit endorsement applies.
ENDORSEMENTS Form Number Enter identifier: The number used by the insurer for this form.
ENDORSEMENTS Title Enter text: The name of the form.
ENDORSEMENTS Edition Date Enter date: The edition date of the form.
ENDORSEMENTS ODL-For Profit Check the box (if applicable): Indicates the outside directorship liability (ODL) for profit endorsement applies.
ENDORSEMENTS Form Number Enter identifier: The number used by the insurer for this form.
ENDORSEMENTS Title Enter text: The name of the form.
ENDORSEMENTS Edition Date Enter date: The edition date of the form.
ENDORSEMENTS Professional Services Coverage Check the box (if applicable): Indicates the professional services coverage endorsement applies.
ENDORSEMENTS Form Number Enter identifier: The number used by the insurer for this form.
ENDORSEMENTS Title Enter text: The name of the form.
ENDORSEMENTS Edition Date Enter date: The edition date of the form.
ENDORSEMENTS Blank Space Check the box (if applicable): Indicates the endorsement form described applies to the policy.
ENDORSEMENTS Enter text: The description of the form.
ENDORSEMENTS Enter identifier: The number used by the insurer for this form.
ENDORSEMENTS Enter text: The name of the form.
ENDORSEMENTS Enter date: The edition date of the form.
ENDORSEMENTS Check the box (if applicable): Indicates the endorsement form described applies to the policy.
ENDORSEMENTS Enter text: The description of the form.
ENDORSEMENTS Enter identifier: The number used by the insurer for this form.
ENDORSEMENTS Enter text: The name of the form.
ENDORSEMENTS Enter date: The edition date of the form.
ENDORSEMENTS Check the box (if applicable): Indicates the endorsement form described applies to the policy.
ACORD 807 (2009/02) rev. 02-27-2009 5 of 18

Section Name Field Name Field and/or Section Description
ENDORSEMENTS Enter text: The description of the form.
ENDORSEMENTS Enter identifier: The number used by the insurer for this form.
ENDORSEMENTS Enter text: The name of the form.
ENDORSEMENTS Enter date: The edition date of the form.
ENDORSEMENTS Check the box (if applicable): Indicates the endorsement form described applies to the policy.
ENDORSEMENTS Enter text: The description of the form.
ENDORSEMENTS Enter identifier: The number used by the insurer for this form.
ENDORSEMENTS Enter text: The name of the form.
ENDORSEMENTS Enter date: The edition date of the form.
ENDORSEMENTS Check the box (if applicable): Indicates the endorsement form described applies to the policy.
ENDORSEMENTS Enter text: The description of the form.
ENDORSEMENTS Enter identifier: The number used by the insurer for this form.
ENDORSEMENTS Enter text: The name of the form.
ENDORSEMENTS Enter date: The edition date of the form.
ENDORSEMENTS Check the box (if applicable): Indicates the endorsement form described applies to the policy.
ENDORSEMENTS Enter text: The description of the form.
ENDORSEMENTS Enter identifier: The number used by the insurer for this form.
ENDORSEMENTS Enter text: The name of the form.
ENDORSEMENTS Enter date: The edition date of the form.
ENDORSEMENTS Check the box (if applicable): Indicates the endorsement form described applies to the policy.
ENDORSEMENTS Enter text: The description of the form.
ENDORSEMENTS Enter identifier: The number used by the insurer for this form.
ENDORSEMENTS Enter text: The name of the form.
ENDORSEMENTS Enter date: The edition date of the form.
FINANCIAL STATEMENT INFORMATION Date of Financial Information Enter date: This is the date attributed to the financial information. As used here, the date the financial information was prepared.
FINANCIAL STATEMENT INFORMATION Period of Financial Information From: Enter date: The starting date of the financial information (MM/DD/YYYY).
FINANCIAL STATEMENT INFORMATION Period of Financial Information To: Enter date: The end date of the financial information (MM/DD/YYYY).
FINANCIAL STATEMENT INFORMATION Outside Auditor Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Is there is an outside auditor?”.
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Section Name Field Name Field and/or Section Description
FINANCIAL STATEMENT INFORMATION Any changes to the outside financial auditor in the last three (3) years? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Any changes to the outside financial auditor in the last specified number of years?”.
FINANCIAL STATEMENT INFORMATION Has any auditor issued a “going concern” opinion for the applicant’s or any of its subsidiaries financial statements? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Has any Auditor issued a “Going Concern” Opinion for the Applicants or any of its Subsidiaries Financial Statements?”.
FINANCIAL STATEMENT INFORMATION Current Year: Enter year: The year of the current financial information.
FINANCIAL STATEMENT INFORMATION Current Year: Total Assets Enter amount: The total assets of the organization for the current year.
FINANCIAL STATEMENT INFORMATION Current Year: Current Assets Enter amount: The amount of assets that are cash or are convertible into cash at short notice for the current year.
FINANCIAL STATEMENT INFORMATION Current Year: Inventory Enter amount: The inventory amount for the current year.
FINANCIAL STATEMENT INFORMATION Current Year: Cash Enter amount: The cash amount for the current year.
FINANCIAL STATEMENT INFORMATION Current Year: Current Liabilities Enter amount: The amount of debt that becomes due within one year for the current year.
FINANCIAL STATEMENT INFORMATION Current Year: Total Liabilities Enter amount: The total liabilities of the organization for the current year.
FINANCIAL STATEMENT INFORMATION Current Year: Total Revenue Enter amount: The total revenue for the organization for the current year.
FINANCIAL STATEMENT INFORMATION Current Year: Net Income / Loss Enter amount: The excess amount of revenue over expenses for the current year. This may be a net loss amount.
FINANCIAL STATEMENT INFORMATION Prior Year: Enter year: The year of the prior financial information.
FINANCIAL STATEMENT INFORMATION Prior Year: Total Assets Enter amount: The total assets of the organization for the prior year.
FINANCIAL STATEMENT INFORMATION Prior Year: Current Assets Enter amount: The amount of assets that are cash or are convertible into cash at short notice for the prior year.
FINANCIAL STATEMENT INFORMATION Prior Year: Inventory Enter amount: The inventory amount for the prior year.
FINANCIAL STATEMENT INFORMATION Prior Year: Cash Enter amount: The cash amount for the prior year.
ACORD 807 (2009/02) rev. 02-27-2009 7 of 18

Section Name Field Name Field and/or Section Description
FINANCIAL STATEMENT INFORMATION Prior Year: Current Liabilities Enter amount: The amount of debt that becomes due within one year for the prior year.
FINANCIAL STATEMENT INFORMATION Prior Year: Total Liabilities Enter amount: The total liabilities of the organization for the prior year.
FINANCIAL STATEMENT INFORMATION Prior Year: Total Revenue Enter amount: The total revenue for the organization for the prior year.
FINANCIAL STATEMENT INFORMATION Prior Year: Net Income / Loss Enter amount: The excess amount of revenue over expenses for the prior year. This may be a net loss amount.
NOT FOR PROFIT Current Year Fund Balance (Net Assets) Enter amount: The fund balance (net assets) amount for the current year.
NOT FOR PROFIT Prior Year Fund Balance (Net Assets) Enter amount: The fund balance (net assets) amount for the prior year.
NOT FOR PROFIT Organization Tax Exempt (Y / N) Enter Y for a “Yes” response. Input N for “No” response. Indicates if the organization is exempt from certain taxes to be paid to the federal government or foreign equivalent.
PRIVATE Parent Company / Organization Enter text: The name of the parent organization.
PRIVATE Number Of Owners Enter number: The number of owners.
PRIVATE Number Of Voting Shares Outstanding Enter number: The number of shares outstanding in the voting shares class.
PRIVATE Total Number Of Voting Shares Enter number: The total number of voting shares, including shares not released to the marketplace.
PRIVATE Voting Shares Owned By Directors Enter number: The total number of voting shares owned by members of the board of directors
PRIVATE Voting Shares Owned By Officers Enter number: Total number of voting shares owned by officers who are not directors.
IDENTIFICATION SECTION Agency Customer ID Enter identifier: The customer’s identification number assigned by the producer (e.g. agency or brokerage).
OWNERSHIP / ORGANIZATION STRUCTURE Name Enter text: The full name of the director or officer of the organization.
OWNERSHIP / ORGANIZATION STRUCTURE Affiliation With Other Organizations Enter text: The name of the affiliated organization.
OWNERSHIP / ORGANIZATION STRUCTURE Name Enter text: The full name of the director or officer of the organization.
ACORD 807 (2009/02) rev. 02-27-2009 8 of 18

Section Name Field Name Field and/or Section Description
OWNERSHIP / ORGANIZATION STRUCTURE Affiliation With Other Organizations Enter text: The name of the affiliated organization.
OWNERSHIP / ORGANIZATION STRUCTURE Name Enter text: The full name of the director or officer of the organization.
OWNERSHIP / ORGANIZATION STRUCTURE Affiliation With Other Organizations Enter text: The name of the affiliated organization.
OWNERSHIP / ORGANIZATION STRUCTURE Name Enter text: The full name of the director or officer of the organization.
OWNERSHIP / ORGANIZATION STRUCTURE Affiliation With Other Organizations Enter text: The name of the affiliated organization.
OWNERSHIP / ORGANIZATION STRUCTURE Name Enter text: The full name of the director or officer of the organization.
OWNERSHIP / ORGANIZATION STRUCTURE Affiliation With Other Organizations Enter text: The name of the affiliated organization.
OWNERSHIP / ORGANIZATION STRUCTURE Name Enter text: The full name of the director or officer of the organization.
OWNERSHIP / ORGANIZATION STRUCTURE Affiliation With Other Organizations Enter text: The name of the affiliated organization.
OWNERSHIP / ORGANIZATION STRUCTURE Name Enter text: The full name of the director or officer of the organization.
OWNERSHIP / ORGANIZATION STRUCTURE Affiliation With Other Organizations Enter text: The name of the affiliated organization.
OWNERSHIP / ORGANIZATION STRUCTURE Name Enter text: The full name of the director or officer of the organization.
ACORD 807 (2009/02) rev. 02-27-2009 9 of 18

Section Name Field Name Field and/or Section Description
OWNERSHIP / ORGANIZATION STRUCTURE Affiliation With Other Organizations Enter text: The name of the affiliated organization.
OWNERSHIP / ORGANIZATION STRUCTURE Name Enter text: The full name of the director or officer of the organization.
OWNERSHIP / ORGANIZATION STRUCTURE Affiliation With Other Organizations Enter text: The name of the affiliated organization.
OWNERSHIP / ORGANIZATION STRUCTURE Name Enter text: The full name of the director or officer of the organization.
OWNERSHIP / ORGANIZATION STRUCTURE Affiliation With Other Organizations Enter text: The name of the affiliated organization.
OWNERSHIP / ORGANIZATION STRUCTURE Name Enter text: The additional interest’s full name.
OWNERSHIP / ORGANIZATION STRUCTURE Title Enter text: The title this person has in the current employment position.
OWNERSHIP / ORGANIZATION STRUCTURE Responsibility Enter text: The description of the duties in the organization of the individual.
OWNERSHIP / ORGANIZATION STRUCTURE Affiliation With Other Organizations Enter text: The name of the affiliated organization.
OWNERSHIP / ORGANIZATION STRUCTURE Name Enter text: The additional interest’s full name.
OWNERSHIP / ORGANIZATION STRUCTURE Title Enter text: The title this person has in the current employment position.
OWNERSHIP / ORGANIZATION STRUCTURE Responsibility Enter text: The description of the duties in the organization of the individual.
ACORD 807 (2009/02) rev. 02-27-2009 10 of 18

Section Name Field Name Field and/or Section Description
OWNERSHIP / ORGANIZATION STRUCTURE Affiliation With Other Organizations Enter text: The name of the affiliated organization.
OWNERSHIP / ORGANIZATION STRUCTURE Name Enter text: The additional interest’s full name.
OWNERSHIP / ORGANIZATION STRUCTURE Title Enter text: The title this person has in the current employment position.
OWNERSHIP / ORGANIZATION STRUCTURE Responsibility Enter text: The description of the duties in the organization of the individual.
OWNERSHIP / ORGANIZATION STRUCTURE Affiliation With Other Organizations Enter text: The name of the affiliated organization.
OWNERSHIP / ORGANIZATION STRUCTURE Name Enter text: The name of the subsidiary of the company. This may also contain owned foundations or charitable trusts.
OWNERSHIP / ORGANIZATION STRUCTURE Nature Of Business Enter text: The description of the nature/type of business.
OWNERSHIP / ORGANIZATION STRUCTURE Date Acquired / Created Enter date: The date the subsidiary, foundation or charitable trust was acquired / created.
OWNERSHIP / ORGANIZATION STRUCTURE Percent Ownership By Parent Enter percentage: The percent of ownership by the parent company.
OWNERSHIP / ORGANIZATION STRUCTURE Name Enter text: The name of the subsidiary of the company. This may also contain owned foundations or charitable trusts.
OWNERSHIP / ORGANIZATION STRUCTURE Nature Of Business Enter text: The description of the nature/type of business.
OWNERSHIP / ORGANIZATION STRUCTURE Date Acquired / Created Enter date: The date the subsidiary, foundation or charitable trust was acquired / created.
ACORD 807 (2009/02) rev. 02-27-2009 11 of 18

Section Name Field Name Field and/or Section Description
OWNERSHIP / ORGANIZATION STRUCTURE Percent Ownership By Parent Enter percentage: The percent of ownership by the parent company.
OWNERSHIP / ORGANIZATION STRUCTURE Name Enter text: The name of the subsidiary of the company. This may also contain owned foundations or charitable trusts.
OWNERSHIP / ORGANIZATION STRUCTURE Nature Of Business Enter text: The description of the nature/type of business.
OWNERSHIP / ORGANIZATION STRUCTURE Date Acquired / Created Enter date: The date the subsidiary, foundation or charitable trust was acquired / created.
OWNERSHIP / ORGANIZATION STRUCTURE Percent Ownership By Parent Enter percentage: The percent of ownership by the parent company.
OWNERSHIP / ORGANIZATION STRUCTURE Name Enter text: The name of the subsidiary of the company. This may also contain owned foundations or charitable trusts.
OWNERSHIP / ORGANIZATION STRUCTURE Nature Of Business Enter text: The description of the nature/type of business.
OWNERSHIP / ORGANIZATION STRUCTURE Date Acquired / Created Enter date: The date the subsidiary, foundation or charitable trust was acquired / created.
OWNERSHIP / ORGANIZATION STRUCTURE Percent Ownership By Parent Enter percentage: The percent of ownership by the parent company.
OWNERSHIP / ORGANIZATION STRUCTURE Name Enter text: The name of the subsidiary of the company. This may also contain owned foundations or charitable trusts.
OWNERSHIP / ORGANIZATION STRUCTURE Nature Of Business Enter text: The description of the nature/type of business.
OWNERSHIP / ORGANIZATION STRUCTURE Date Acquired / Created Enter date: The date the subsidiary, foundation or charitable trust was acquired / created.
ACORD 807 (2009/02) rev. 02-27-2009 12 of 18

Section Name Field Name Field and/or Section Description
OWNERSHIP / ORGANIZATION STRUCTURE Percent Ownership By Parent Enter percentage: The percent of ownership by the parent company.
OWNERSHIP / ORGANIZATION STRUCTURE Name Enter text: The name of the subsidiary of the company. This may also contain owned foundations or charitable trusts.
OWNERSHIP / ORGANIZATION STRUCTURE Nature Of Business Enter text: The description of the nature/type of business.
OWNERSHIP / ORGANIZATION STRUCTURE Date Acquired / Created Enter date: The date the subsidiary, foundation or charitable trust was acquired / created.
OWNERSHIP / ORGANIZATION STRUCTURE Percent Ownership By Parent Enter percentage: The percent of ownership by the parent company.
OWNERSHIP / ORGANIZATION STRUCTURE Name Enter text: The full name of the shareholder.
OWNERSHIP / ORGANIZATION STRUCTURE Member of Board Enter Y for a “Yes” response. Input N for “No” response. Indicates if the shareholder is represented on the board of directors.
OWNERSHIP / ORGANIZATION STRUCTURE Percent Owned Enter percentage: The percent of shares owned.
OWNERSHIP / ORGANIZATION STRUCTURE Name Enter text: The full name of the shareholder.
OWNERSHIP / ORGANIZATION STRUCTURE Member of Board Enter Y for a “Yes” response. Input N for “No” response. Indicates if the shareholder is represented on the board of directors.
OWNERSHIP / ORGANIZATION STRUCTURE Percent Owned Enter percentage: The percent of shares owned.
OWNERSHIP / ORGANIZATION STRUCTURE Name Enter text: The full name of the shareholder.
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Section Name Field Name Field and/or Section Description
OWNERSHIP / ORGANIZATION STRUCTURE Member of Board Enter Y for a “Yes” response. Input N for “No” response. Indicates if the shareholder is represented on the board of directors.
OWNERSHIP / ORGANIZATION STRUCTURE Percent Owned Enter percentage: The percent of shares owned.
OWNERSHIP / ORGANIZATION STRUCTURE Name Enter text: The full name of the shareholder.
OWNERSHIP / ORGANIZATION STRUCTURE Member of Board Enter Y for a “Yes” response. Input N for “No” response. Indicates if the shareholder is represented on the board of directors.
OWNERSHIP / ORGANIZATION STRUCTURE Percent Owned Enter percentage: The percent of shares owned.
OWNERSHIP / ORGANIZATION STRUCTURE Name Enter text: The full name of the shareholder.
OWNERSHIP / ORGANIZATION STRUCTURE Member of Board Enter Y for a “Yes” response. Input N for “No” response. Indicates if the shareholder is represented on the board of directors.
OWNERSHIP / ORGANIZATION STRUCTURE Percent Owned Enter percentage: The percent of shares owned.
OWNERSHIP / ORGANIZATION STRUCTURE Name Enter text: The full name of the shareholder.
OWNERSHIP / ORGANIZATION STRUCTURE Member of Board Enter Y for a “Yes” response. Input N for “No” response. Indicates if the shareholder is represented on the board of directors.
OWNERSHIP / ORGANIZATION STRUCTURE Percent Owned Enter percentage: The percent of shares owned.
Section Name Field Name Field and/or Section Description
OWNERSHIP / ORGANIZATION STRUCTURE Do All Shareholders That Own 5% Or More Of the Voting Shares Have a Representative On the Board of Directors? (Y / N) Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Do All Shareholders that Own 5% or more of the Voting Shares, either directly or beneficially, have a Representative on the Board of Directors?”.
OWNERSHIP / ORGANIZATION STRUCTURE If No Shareholders Own More Than 5% Or More, Please Initial Here: Initial here: The named insured’s initials.
OWNERSHIP / ORGANIZATION STRUCTURE List Name of Parent Company Enter text: The name of the parent organization.
GENERAL INFORMATION 1. DURING THE LAST FIVE (5) YEARS HAS THE APPLICANT OR ANY DIRECTOR, OFFICER, MEMBERS OF THE BOARD OF MANAGERS OR ANY OTHER PROPOSED INSURED BEEN INVOLVED IN ANY CLAIMS, LAWSUITS OR ADMINISTRATIVE PROCEEDINGS? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “During the last specified number of years, has the applicant or any director, officer, members of the board of managers or any other proposed insured been involved in any claims, lawsuits or administrative proceedings?”.
GENERAL INFORMATION Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation.
GENERAL INFORMATION 2. ANY CHANGES IN THE BOARD OF DIRECTORS OR SENIOR MANAGEMENT IN THE LAST THREE (3) YEARS? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Any changes in the Board of Directors or senior management in the last specified number of years?”.
GENERAL INFORMATION Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation.

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Section Name Field Name Field and/or Section Description
GENERAL INFORMATION 3. DURING THE LAST THREE (3) YEARS, HAS THE APPLICANT COMPLETED OR AGREED TO, OR IS CONTEMPLATING WITHIN THE NEXT 12 MONTHS; A MERGER, ACQUISITION OR CONSOLIDATION WITH ANOTHER ENTITY? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “During the last specified number of years, has the applicant completed or agreed to, or is contemplating within the next 12 months; a merger, acquisition or consolidation with another entity?”.
GENERAL INFORMATION Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation.
GENERAL INFORMATION 4. DURING THE LAST THREE (3) YEARS, HAS THE APPLICANT COMPLETED OR AGREED TO, OR IS CONTEMPLATING WITHIN THE NEXT 12 MONTHS; ANY REGISTRATION FOR A PUBLIC OFFERING OR ANY PRIVATE PLACEMENT OF SECURITIES? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “During the last past specified number of years, has the applicant completed or agreed to or is contemplating within the next 12 months any registration for a public offering or any private placement of securities?”.
GENERAL INFORMATION Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation.
GENERAL INFORMATION 5. DURING THE LAST THREE (3) YEARS, HAS THE APPLICANT COMPLETED OR AGREED TO, OR IS CONTEMPLATING WITHIN THE NEXT 12 MONTHS; A REORGANIZATION OR ARRANGEMENT WITH CREDITORS UNDER FEDERAL OR STATE LAW? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “During the past specified number of years, has the applicant completed or agreed to or is contemplating within the next 12 months a reorganization or arrangement with creditors under federal or state law?”.
GENERAL INFORMATION Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation.
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Section Name Field Name Field and/or Section Description
GENERAL INFORMATION 6. DOES THE APPLICANT OR ANY OF ITS SUBSIDIARIES ACT AS A GENERAL PARTNER IN ANY PARTNERSHIP OR ARE INVOLVED IN ANY JOINT VENTURES? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Does the applicant or any of its subsidiaries act as a general partner in any partnership or are involved in any joint ventures?”.
GENERAL INFORMATION Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation.
IDENTIFICATION SECTION Agency Customer ID Enter identifier: The customer’s identification number assigned by the producer (e.g. agency or brokerage).
GENERAL INFORMATION (continued) 7. ARE ANY PERSONS OR ENTITIES PROPOSED FOR THIS INSURANCE, AWARE OF ANY FACT, CIRCUMSTANCE, ACT, ERROR, OMISSION, OR SITUATION WHICH MAY GIVE RISE TO A CLAIM THAT WOULD FALL WITHIN THE SCOPE OF THE PROPOSED INSURANCE? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Are any persons or entities proposed for this insurance aware of any fact, circumstance, act, error, omission, or situation which may give rise to a claim that would fall within the scope of the proposed insurance?”.
GENERAL INFORMATION (continued) If “Yes”, has the policyholder or any insured individual, given written notice under the provisions of any prior or current insurance policy? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Has the policyholder or any insured individual given written notice under the provisions of any prior or current insurance policy of specific facts or circumstances which might give rise to a claim being made against any insured for any proposed insurance?”.
GENERAL INFORMATION Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation.
GENERAL INFORMATION 8. HAS ANY INSURER REFUSED, CANCELLED, NON-RENEWED, OR STATED AN INTENT TO NONRENEW YOUR D&O INSURANCE? (Not applicable in Missouri) Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Has any insurer refused, cancelled, non-renewed, or stated an intent to non-renew your D&O insurance? (Not applicable in Missouri)”.
GENERAL INFORMATION Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation.
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Section Name Field Name Field and/or Section Description
GENERAL INFORMATION 9. ARE ANY OF THE APPLICANTS’ SECURITIES OR THOSE OF ITS SUBSIDIARIES, PUBLICLY TRADED OR SUBJECT TO PUBLIC REPORTING UNDER THE SECURITIES EXCHANGE COMMISSION ACT OF 1934? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Are any of the applicants securities, or those of its subsidiaries publicly traded or subject to public reporting under the Securities Exchange Commission Act of 1934?”.
GENERAL INFORMATION Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation.
GENERAL INFORMATION 10. HAS THE APPLICANT HAD A BREACH OF DEBT COVENANT OR LOAN AGREEMENT? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Has the applicant had a breach of debt covenant or loan agreement?”.
GENERAL INFORMATION Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation.
GENERAL INFORMATION 11. DOES THE APPLICANT PROVIDE ANY CONSULTING AND/OR PROFESSIONAL SERVICES? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Does the applicant provide any consulting and/or professional services?”.
GENERAL INFORMATION Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation.
ATTACHMENTS Resume(s) Check the box (if applicable): Indicate a resume is attached.
ATTACHMENTS Warranty(ies) Check the box (if applicable): Indicates a warranty is attached.
ATTACHMENTS Registration Statement(s) Check the box (if applicable): Indicates a registration statement is attached.
ATTACHMENTS Private Placement Memoranda Check the box (if applicable): Indicates a private placement memoranda is attached.
ATTACHMENTS Schedule of Shareholders Check the box (if applicable): Indicates a schedule of shareholders is attached.
ATTACHMENTS Other Check the box (if applicable): Indicates there are attachments to the policy other than those listed.
ATTACHMENTS Other Description Enter text: The description of the attachment.
ATTACHMENTS Other Check the box (if applicable): Indicates there are attachments to the policy other than those listed.
ATTACHMENTS Other Description Enter text: The description of the attachment.
ATTACHMENTS Other Check the box (if applicable): Indicates there are attachments to the policy other than those listed.
ATTACHMENTS Other Description Enter text: The description of the attachment.
Section Name Field Name Field and/or Section Description
REMARKS Remarks Enter text: The remarks associated with the directors and officers line of business. Use this section to list any additional, pertinent information that the underwriter should know about the overall exposures of this risk. Attached ACORD 101, Additional Remarks Schedule, if more space is needed.
SIGNATURE Applicant’s Name Enter text: The named insured(s) as it/they will appear on the policy declarations page.
SIGNATURE Applicant’s Title Enter text: The title of the individual in the organization or his relationship to the organization.
SIGNATURE Applicant’s Signature Sign here: Accommodates the signature of the applicant or named insured. As used here, upon completion of the full commercial lines application series, the insured should review the applications and sign this form in the available space.
SIGNATURE Date Enter date: The date the form was signed by the named insured.
SIGNATURE Producer’s Signature Sign here: Accommodates the signature of the authorized representative (e.g. producer, agent, broker, etc.). by all companies to issue Certificates. This is required in most states.
SIGNATURE National Producer Number Enter identifier: The National Producer Number (NPN) as defined in the National Insurance Producer Registry (NIPR). Note: The NPN is not the same as the producer state license number.
Edition Date The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM).