Directors & Officers Liability Insurance Application

Lions Club / District International
Non Profit Directors and Officers Liability
Flexi Plus Five Application

This is an application for a claims made policy. Please read your policy carefully.

All fields are required. Use N/A if not applicable.

CLUB MEMBERS	LIMIT OF LIABILITY / PREMIUMS
CLUB MEMBERS	$500,000 limit per claim/aggregate	$1,000,000 limit per claim/aggregate
0 to 25 Members	$350	$400
26 to 50 Members	$400	$450
51 to 75 Members	$450	$500
76 to 100 Members	$500	$550
101 + Members	Individually Priced	Individually Priced

** $1,000 per claim deductible per coverage line applies.
*** Louisiana will be written on a non-admitted basis. Please submit your application to Philadelphia Insurance for rating.
**** If you are located in FL, KY, NJ, or WV please submit your application to Philadelphia Insurance for rating.

Lions Club/District:
Address:	Address Cont:
City:	State: Zip Code:
Telephone Number:	Fax Number:
Website: http://
Contact Name:	Contact Title:
Contact Phone Number:	Contact Email:

If a District, how many Clubs:	Members:
If a club, how many members:	Volunteers (Annually):

Financial Information:	Current Year	Previous Year
Annual Revenue	$	$

DIRECTORS AND OFFICERS

Directors and Officers Liability Insurance has been continuously in force since:
Has the Applicant (or any person proposed for coverage) herein been the subject of, or involved in, any of the following in the past 5 years?
If yes, please provide details.
Anti-trust, copyright or patent litigation?	Yes	No
Any disciplinary action by any regulatory agency or association?	Yes	No
Any action where a license was revoked or suspended?	Yes	No
Any administrative proceeding charging violation of a federal or state law or regulation?	Yes	No
Any other criminal actions?	Yes	No
It is agreed that with respect to the above questions, if such circumstances exist, any claim arising from such circumstances are excluded from the proposed insurance.
In the past 24 months or the next 12 months, has the Applicant been or anticipate being involved in any of the following?
If yes, please provide details.
Creation of any new subsidiaries?	Yes	No
Mergers, acquisitions or consolidation with another entity?	Yes	No
Changes in the board of directors or senior management (other than death or retirement)?	Yes	No

GENERAL SUMMARY

Has the Applicant, in the past five years, given written notice under the provisions of any prior policies providing similar insurance of a claim, or of specific facts or circumstances which might give rise to a claim being made against any person or entity applying for this insurance?	Yes	No
If yes, please provide details for each incident.

No person applying for this coverage is aware of any facts or circumstances which he or she has reason to suppose might give rise to a future claim that would fall within the scope of any of the proposed coverage's for which the Applicant has applied, except:
None or as noted below.

Coverage effective date is subject to receipt, review, and acceptance by Company Underwriter.

Material Change
If there is any material change to the answers of this Application's questions prior to the policy inception date, the Applicant must notify the Underwriter in writing. Any outstanding quotation may be modified or withdrawn.

WARNING: 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.

You must agree to the Fraud Notice Statements

The Undersigned warrants that to the best of his/her knowledge and belief the statements set forth herein are true. The Undersigned further declares that any occurrence or event that takes place prior to the effective date of the insurance applied for which may render inaccurate, untrue, or incomplete any statement made will immediately be reported in writing to the Underwriter. The Underwriter may withdraw or modify any outstanding quotations and/or authorization or agreement to bind the insurance. The Underwriter is hereby authorized to make any investigation and inquiry in connection with the information, statements and disclosures provided in this Application. The signing of this Application does not bind the Undersigned to purchase the insurance, nor does the review of this Application bind the insurance company to issue a policy. It is agreed that this Application shall be the basis of the contract should a policy be issued. This Application will be attached and become a part of the policy.

Name	Title	(MUST BE SIGNED BY THE CLUB PRESIDENT, SECRETARY OR TREASURER / DISTRICT GOVERNOR, SECRETARY OR TREASURER FOR DISTRICT)
Date	Authorized Signature (if submitting paper copy)
The above signed warrants that he/she is authorized and has the power to complete and execute this Application, including the Warranty Statement on behalf of the Applicant and their respective Directors, Officers or other insured persons.

Custom web development, hosting and implementation provided by Alkon Consulting

Directors & Officers Liability Insurance Application

Lions Club / District InternationalNon Profit Directors and Officers LiabilityFlexi Plus Five Application

This is an application for a claims made policy. Please read your policy carefully.

All fields are required. Use N/A if not applicable.

Lions Club / District International
Non Profit Directors and Officers Liability
Flexi Plus Five Application