Directors and Officers Liability

Personal Details

Agreement

Risk Details

General Policy Details

Personal Details

Proposer Type

Are You a Shareholder?

Intermediary

Agent Name/Code

Binder

ID Type

ID Number

TIN Number

Proposer First Name

Proposer Middle Name

Proposer Last Name

Is there any Care of/Account of/and?

Please specify name

Type of Business

Occupation

Date Of Birth

Gender

Male Female

Is the insurance being purchased for self? (if no, state your details)

First Name

Middle Name

Last Name

Applicant Contact & Other Details

Contact Details

Mobile No.

Telephone No.

Fax No.

Region/City

Zone/Sub City

Woreda/District

Kebele

P.O. Box No.

H.No.

Email Address

Which Berhan Insurance S.C. branch do you want to be served from?

Physical Address

Non-Disclosure/Misstatement/Misrepresentation It is the duty of the proposer to disclose all material facts relevant to the risk. A material fact is one that is likely to influence our judgment and acceptance of your proposal. If your proposal is a renewal it should include any change in facts previously advised to us. If you are in any doubt about facts considered material, disclose them. Please note that failure to disclose a material fact or if any information provided proves to be incorrect may invalidate this insurance or any claim made under it.

I agree to the statement mentioned above

Risk Details

Insurance Start Date

Insurance End Date

Location Details

Name of Building

Name of Street

Area/Estate

Region/City

Zone/Sub City

City/Town

What is the policy holder’s business activity?

Risk Category

Is the policy holder is a legal entity?

Please provide directors and officers details

Name of the Directors / Officers

Duties/Role

Add

For how many years has the policy holder been in business?

Has the proposed policy holder ever been declared bankrupt or insolvent?

History of the Company

During the last five years has:

The name of the company changed?

Any acquisition or merger involving the company taken place?

Has the intention been presented for approval by the shareholders?

Any subsidiary company been sold or ceased trading?

Complete list of the local and foreign subsidiaries and sub-subsidiaries with the percentage held directly or indirectly, also indicate it if you want it/them to be covered under your policy:

Subsidiaries/Sub-Subsidiaries Details 1

Name

Country of Registration

Date of establishment

Percentage of Shares held directly or indirectly

Coverage

The capital structure of the company changed?

Any right issue taken place?

The company changed its external auditors or legal advisers?

Structure of the Company

Is the company:

Private

Public

Listed on the London Stock Exchange?

Listed on any other Stock Exchange?

Country

Stock Exchange

Since When

Share Value

Total number of shares traded on the stock exchange

Please list all shareholdings representing 15% or more of the company’s ordinary share capital and their respective percentage of the holding.

Shareholder and Percentage Details

Name of the Share Holder

Percentage of Shareholding

Add

Forward looking

Does the company have any acquisitions, tender offers or merger pending or under consideration?

Is the company aware of any proposal relating to its acquisition by another company in the next year?

Is the company intending a public or private offering of securities within the next year?

Current insurance arrangements

Does the company have directors & officer’s liability insurance currently in force?

Has the company already had directors & officer’s liability insurance?

Claims History

Have claims ever been made against any past or present director or officer of the company or its subsidiaries?

Is the proposer aware, after enquiry, of any circumstance or incident, which may give rise to claim against any director or officer of the company in such capacity?

Is the proposer aware, after prosecution (after or pending) of the company or any director or officer?

Has the company or any director or officers ever been subjected to any disciplinary action, been fired and penalized, or been the subject of any regulatory investigation and enquiry?

Limit of Liability

Any one claim

Any one event

Any One Period

General Policy Details

Are you now or have you ever been insured for this type of policy ?

Has any insurance company ever

Declined your proposal ?

Cancelled or refused to renew your policy?

Required an increased premium or imposed special conditions?

Declined your claim?

Required you to carry the first portion of any loss?

Insurance and Loss History

Please provide below information on any insurance claims you have reported in the last 3 years

Type of loss

Year of Incident

Claim Amount/ Value

Add Loss

DECLARATION AND CONSENT | Please Read Carefully *

I the undersigned declare that the vehicle(s) described (is/are) in good condition and will continue to be maintained and I hereby warrant that the above statement and particulars are true and I hereby agree that declaration shall be deemed to be of a promissory nature and effect and the basis of the contract between me and the Company and that I have not withheld any important information which should be communicated to the Company and that I am willing to accept a policy subject to the terms, conditions and exceptions therein and to pay the premium agreed upon.

CREDIT INFORMATION | Please Read Carefully *

I/we do hereby confirm that I/we have authorized Berhan Insurance S.C. to share my/our credit information and to access my/our credit profile from Credit Reference Bureau (C.R.B)

Directors and Officers Liability Proposal

Personal Details

Contact Details

Risk Details

Location Details

Please provide directors and officers details

History of the Company

Complete list of the local and foreign subsidiaries and sub-subsidiaries with the percentage held directly or indirectly, also indicate it if you want it/them to be covered under your policy:

Subsidiaries/Sub-Subsidiaries Details 1

Structure of the Company

Please list all shareholdings representing 15% or more of the company’s ordinary share capital and their respective percentage of the holding.

Shareholder and Percentage Details

Forward looking

Current insurance arrangements

Claims History

Limit of Liability

General Policy Details

Has any insurance company ever

Insurance and Loss History

DECLARATION AND CONSENT | Please Read Carefully *

CREDIT INFORMATION | Please Read Carefully *