OBF

Please note:

• This is a proposal form for a policy relating to claims made against the Insured during the period of the policy only – CLAIMS MADE.
• Please answer all the questions giving full and complete answers. Please use a separate sheet of paper if insufficient space. If necessary please write additional relevant facts on a separate sheet of paper.
• The proposal form must be completed and signed & dated by a person who is of legal capacity and have the authorisation to request Directors & Officers Liability insurance for the Proposer.
• This form does not bind the Proposer but will form part of the Insurance contract if taken up.

Please supply the following information:
The last Annual Report & Accounts for the company
The last Interim Report (if applicable)

Step 1 of X

Name of Parent Company Address of Head Office Website Address Country of Registration Please state how long the Company has continuously carried on business Describe the business activities of the Company

Step 2 of X

During the past 5 years has:

The name of the Company changed?

Yes No

Any acquisition or merger taken place?

Yes No

Any subsidiary been sold/ceased trading?

Yes No

Any Rights Issue taken Place?

Yes No

The capital structure of the Company changed?

Yes No

The Company changed its external auditors or legal advisors?

Yes No If Yes to any of the above, please provide full details

Step 3 of X

Has the Company publicly revealed that it has under consideration at the present time any acquisitions, mergers or tender offers? If Yes, please provide full details: Is the Company aware of any proposal relating to its acquisition by another company within the next year? If Yes, please provide full details: Is the Company intending a public or private offering of securities within the next year? If Yes, please provide full details:

Step 4 of X

Is the company:

Private?

Yes No

Public?

Yes No

Listed on the London Stock Exchange?

Yes No

Listed on any other Stock Exchange?

Yes No If the answer is Yes to any of the above, please provide full details:

Step 5 of X

Please list below the full names of all persons who, at the date of this proposal form, are Directors or Officers of the Company and the capacity in which they respectively serve.

Step 6 of X

Please list details of Subsidiary Companies that you wish to be included under this Insurance:

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