Contact Information:
Jason Rogers
Vice President
Gallagher Affinity
Jason_Rogers@ajg.com
(941) 757-1443
Application for Insurance (D&O, EPL, Fiduciary, Crime and Kidnap & Ransom Coverage Parts)
State*
4. Nature of the Applicant's business*
5. Total number of employees*
6. Applicant's total revenues during the most recently concluded fiscal year end*
7. Applicant's total assets as of the most recent fiscal year end*
8. Does the Applicant now have recognized tax-exempt status under the U.S. Internal Revenue Code?*
9. In the next 12 months is the Applicant contemplating any merger/acquisition/divestment/sale of securities/location, facility or office closings, consolidations or layoffs/reorganization or arrangement with creditors under federal or state law?*
If Yes, please explain in below text box
Contact Information:
Jason Rogers
Vice President
Gallagher Affinity
Jason_Rogers@ajg.com
(941) 757-1443
Application for Insurance (D&O, EPL, Fiduciary, Crime and Kidnap & Ransom Coverage Parts)
REQUESTED INSURANCE COVERAGE
Insurance Renewal Date (mm/dd/yyyy)*
Directors & Officers Liability
Employment Practices Liability
Contact Information:
Jason Rogers
Vice President
Gallagher Affinity
Jason_Rogers@ajg.com
(941) 757-1443
Application for Insurance (D&O, EPL, Fiduciary, Crime and Kidnap & Ransom Coverage Parts)
DIRECTORS & OFFICERS AND ENTITY INFORMATION
1. During the past 12 months, has there been any change in the composition of the board of directors?*
If Yes, please describe changes in below text box
2. During the past 12 months, has there been any change in services provided by the applicant?*
If Yes, please describe changes in below text box
EMPLOYMENT PRACTICES INFORMATION
1. Within the last year has the Applicant updated its employment practices handbook, its human resources policies or procedures or the structure of its human resources department?*
If Yes, please explain in below text box
2. Number of employees who have left their employment with the Applicant during the past 12 months
3. Does the Applicant have written procedures in place regarding
(i) Equal Opportunity Employement*
(ii) Anti-Discrimination*
(iii) Anti-Sexual Harrassment*
If No to any of the above, please explain in below text box
Contact Information:
Jason Rogers
Vice President
Gallagher Affinity
Jason_Rogers@ajg.com
(941) 757-1443
Application for Insurance (D&O, EPL, Fiduciary, Crime and Kidnap & Ransom Coverage Parts)
1. Please complete the following information regarding the Applicant's employee pension benefits plan(s).
Pension Benefit Plan Name
Plan assets (current year)
Defined Contribution (DC) or Defined Benefit (DB)?
Number of plan participants
Pension Benefit Plan Name
Plan assets (current year)
Defined Contribution (DC) or Defined Benefit (DB)?
Number of plan participants
2. In the next 12 months is the Applicant contemplating (or has the Applicant completed with the last year) merging or terminating any employee benefit plan(s)?*
(a) Allow the employees who reconcile the monthly bank statements to also sign checks, handle deposits and have access to check signing machines or signature plates?*
(b) Have procedures in place to verify the existence and ownership of all new vendors prior to adding them to the authorized master vendor list?*
(c) Verify invoices against a corresponding purchase order, receiving report and the authorized master vendor list prior to issuing payment?*
2. What is the dollar amount above which the Applicant requires countersignature of its checks?*
KIDNAP/RANSOM AND EXTORTION INFORMATION
2. Describe the Applicant's security precautions taken for foreign level by employees