Author: B490144
Last saved by: Peter Taffae
Company: Chubb & Son

| Chubb Group of Insurance Companies 15 Mountain View Rd. Warren, NJ 07059 | Employed Lawyers Professional Liability by Chubb^SM Renewal Application

BY COMPLETING THIS RENEWAL APPLICATION THE APPLICANT IS APPLYING
FOR COVERAGE WITH FEDERAL INSURANCE COMPANY (THE “COMPANY”)
NOTICE: THIS IS A CLAIMS MADE, WHICH APPLIES ONLY TO "CLAIMS" FIRST MADE DURING THE "POLICY PERIOD," OR ANY EXTENDED REPORTING PERIOD.  THE LIMIT OF LIABILITY TO PAY DAMAGES OR SETTLEMENTS WILL BE REDUCED AND MAY BE EXHAUSTED BY "DEFENSE COSTS," AND "DEFENSE COSTS" WILL BE APPLIED AGAINST THE RETENTION AMOUNT.  THE COVERAGE AFFORDED UNDER THIS POLICY DIFFERS IN SOME RESPECTS FROM THAT AFFORDED UNDER OTHER POLICIES.  READ THE ENTIRE RENEWAL APPLICATION CAREFULLY BEFORE SIGNING.
RENEWAL APPLICATION INSTRUCTIONS:
1.	Whenever used in this Renewal Application, the term "Applicant" shall mean the Parent Corporation and all subsidiaries.
2.	Include all requested underwriting information and attachments.  Provide a complete response to all questions and attach additional pages if necessary.
3.	Please sign and date this Application.
I.	NAME, ADDRESS AND CONTACT INFORMATION:
1.	Name of Applicant:  	
2.	Address of Applicant:  	
City:  	  State:  	  Zip Code:  	  Telephone:  	
3.	Applicant’s Web Site:  	
4.	Name and Address (if different than above) of Primary Contact (Executive Officer authorized to receive notices and information regarding the proposed policy):  	
Name:  	  Title:  		  Address:  	
City:  	  State:  	  Zip Code:  	  Telephone:  	  e-Mail:  	
II.	INSURANCE INFORMATION:
1.	Does the Applicant purchase:
a.	directors and officers (D&O) or other management liability insurance?	☐ Yes   ☐ No
b.	employment practices liability (EPL) insurance?	☐ Yes   ☐ No
c.	errors and omissions (E&O) insurance?	☐ Yes   ☐ No
If “Yes” to any of the above, please provide the following:
| D&O | EPL | E&O
Insurance Carrier | | |
Limit of Liability | | |
Deductible/Retention | | |
Expiration Date | | |
III.	GENERAL RISK INFORMATION:
1.	Is the Applicant:	☐ publicly held or   ☐ privately held?
If privately held:
a.	Does the Applicant have any public debt?	☐ Yes   ☐ No
b.	Is the Applicant considering a public offering of debt or equity within the next eighteen (18) months?	☐ Yes   ☐ No 
2.	Is the Applicant planning a merger with, acquisition of or have plans to be acquired by, another entity within the next eighteen (18) months?	☐ Yes   ☐ No
If yes, attach a description of such event.
3.	Please attach:
a.	A copy of the Applicant’s most recent audited year-end financial statements.
b.	A list of any Subsidiaries and description of the operations of each.
IV.	LEGAL DEPARTMENT RISK INFORMATION:  
1.	Provide the total number of:
a.	Employed Lawyers:		
b.	Temporary Attorneys:		
c.	Contract Attorneys:		
2.	Is any Employed Lawyer a member of the Association of Corporate Counsel?	☐ Yes   ☐ No
3.	Do any Employed Lawyers, Temporary Attorneys or Contract Attorneys provide legal services in any of the following practice areas?
a.	Environmental Law & Compliance	☐ Yes   ☐ No
b.	Copyright, Patent, Trademark and Other Intellectual Property Law	☐ Yes   ☐ No
c.	Litigation	☐ Yes   ☐ No
d.	Securities Law	☐ Yes   ☐ No
4.	Do any Employed Lawyers, Temporary Attorneys or Contract Attorneys provide legal services to third parties at the request of the Applicant?	☐ Yes   ☐ No
If “Yes”, describe to whom such services are performed and the nature of such services:

	
5.	Describe the types of legal work typically referred by the Applicant to outside counsel:

	
6.	Do any Employed Lawyers provide Moonlighting Legal Services?	☐ Yes   ☐ No
If “Yes”, describe the scope of services provided and the total number of hours annually.

	
V.	DECLARATIONS, FRAUD WARNINGS AND SIGNATURES:
The Applicant's submission of this Renewal Application does not obligate the Company to issue, or the Applicant  to purchase, a policy.  The Applicant will be advised if the Renewal Application for coverage is accepted.  The Applicant hereby authorizes the Company to make any inquiry in connection with this Renewal Application.
The undersigned authorized agents of the person(s) and entity(ies) proposed for this insurance declare that to the best of their knowledge and belief, after reasonable inquiry, the statements made in this Renewal Application and in any attachments or other documents submitted with this Renewal Application are true and complete.  The undersigned agree that this Renewal Application and such attachments and other documents shall be the basis of the insurance policy should a policy providing the requested coverage be issued; that all such materials shall be deemed to be attached to and shall form a part of any such policy; and that the Company will have relied on all such materials in issuing any such policy.
The information requested in this Renewal Application is for underwriting purposes only and does not constitute notice to the Company under any policy of a Claim or potential Claim.
Notice to Arkansas, New Mexico and Ohio Applicants:  Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false, fraudulent or deceptive statement is, or may be found to be, guilty of insurance fraud, which is a crime, and may be subject to civil fines and criminal penalties.
Notice to Colorado Applicants:  It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company.  Penalties may include imprisonment, fines, denial of insurance, and civil damages.  Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory agencies.
Notice to District of Columbia Applicants:  WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits, if false information materially related to a claim was provided by the applicant.
Notice to Florida Applicants:  Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
Notice to Kentucky Applicants:  Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.
Notice to Louisiana and Rhode Island Applicants:  Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Notice to Maine, Tennessee, Virginia and Washington Applicants:  It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company.  Penalties may include imprisonment, fines or a denial of insurance benefits.
Notice to Alabama and Maryland Applicants:  Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Notice to New Jersey Applicants:  Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.
Notice to Oklahoma Applicants:  Any person who, knowingly and with intent to injure, defraud or deceive any employer or employee, insurance company, or self-insured program, files a statement of claim containing any false or misleading information is guilty of a felony.
Notice to Oregon and Texas Applicants:  Any person who makes an intentional misstatement that is material to the risk may be found guilty of insurance fraud by a court of law.
Notice to Pennsylvania Applicants:  Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
Notice to Puerto Rico Applicants:  Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation with the penalty of a fine of not less than five thousand (5,000) dollars and not more than ten thousand (10,000) dollars, or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances are present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years.
Notice to New York Applicants:  Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to: a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

Date	Signature*	Title
				Chief Executive Officer
				General Counsel
*This Renewal Application must be signed by the chief executive officer and general counsel of the Parent Corporation acting as the authorized representatives of the person(s) and entity(ies) proposed for this insurance.

Produced By:
Agent (Print & Sign):  			
Agency:  	
Agency Taxpayer ID or SS No.:  		Agent License No.:  	
Address:  	
City:  	  State:  	  Zip:  	
Submitted By:
Agency:  	
Agency Taxpayer ID or SS No.:  		Agent License No.:  	
Address:  	
City:  	  State:  	  Zip:

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