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388 Pompton Avenue, P.O. Box 206, Cedar Grove, NJ 07009 1-800-845-1209 • (973) 239-9107 • Fax: (973) 239-6241 www.mhrrg.com Directors & Officers Liability Including Employment Practices Liability Insurance Application c/o Negley Associates 388 Pompton Avenue, P.O. Box 206, Cedar Grove, NJ 07009 1-800-845-1209 • 973-239-9107 • Fax: 973-239-6241 www.mhrrg.com Directors & Officers Liability Including Employment Practices Liability Application For this application to be processed in a timely fashion, please answer every question completely. If a question is not applicable, please write N/A. Do not leave any space blank. 1. Name of Insured ____________________________________________________________________________________ 2. Mailing Address: Street ________________________________________ County ____________________________________________ City__________________________________________ Phone #____________________________________________ State ____________________ Zip__________________ Fax # ______________________________________________ Website_______________________________________ Contact ____________________________________________ 3. Current Directors & Officers Liability Insurance: Insurance Company ___________________________________________________ Premium ____________________ Limit of Liability _____________________________________________________ Deductible ___________________ Policy term: Effective date _______________ Expiration date _________________ Retroactive Date ______________ 4. Limit of l iability requested: $1,000,000 $2,000,000 $3,000,000 $4,000,000 $5,000,000 5. Has any company cancelled or declined to renew insurance ? Yes No (Not applicable to Missouri applicants) If yes, please explain. ________________________________________________________________________________________________________ ____________________________________________________________________________________________________ 6. Year organization founded ____________________________________________________________________________ 7. Projected annual operating budget $___________________________________ (Include current Audited Financial Statement) 8. Is your organization non-profit? Yes No If no, what is the organization’s legal structure? ________________________________________________________________________________________________________ ____________________________________________________________________________________________________ 9. Indicate the detailed purpose and description of business activities of the entity: ________________________________________________________________________________________________________ ____________________________________________________________________________________________________ M APP DO (1/08) Page 1 of 4 c/o Negley Associates 10. Scope of operations: Local State Regional National International 11. Give number of directors_____________________ officers______________________ trustees __________________ full time employees __________________ part time employees ____________________ volunteers _______________ 12. Does the entity or any of its subsidiaries perform or conduct any type of peer review, professional assessment, certification, accreditation or designation of its members? Yes No If yes, please explain. (Attach separate sheet if necessary) ____________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________________ 13. Does the organization have any subsidiaries? Yes No If yes , please list: (Attach separate sheet if necessary) Nonprofit Nature of % of Name For Profit Operations Ownership _____________________________________ ________ _________________________________________ __________ _____________________________________ ________ _________________________________________ __________ _____________________________________ ________ _________________________________________ __________ 14. Are you currently considering the acquisition or creation of any subsidiaries? Yes No If yes, please explain. Explanation should include information as requested in #13. (Attach separate sheet if necessary) _____________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________________ 15. Does the organization have any current EEOC complaints pending? Yes No 16. In the past five (5) years, have any claims been made or are there any now pending against the entity, or any person proposed for this insurance in the capacity as an insured as defined in the policy? Yes No 17. Does the entity or its directors, officers, trustees or employees have any knowledge of pending federal, state or local actions or proceedings against them, or in the past five (5) years have they been involved in any federal, state, or local actions or proceedings? Yes No 18. Is any person proposed for this insurance aware of any fact, circumstance or situation which could reasonably be expected to give rise to any future claim? Yes No (If any or all of questions 15, 16, 17 or 18 are answered yes, please attach a separate sheet explaining the facts, circumstances or situations for each. Any claim or action arising out of such facts, circumstances or situations is excluded from the proposed coverage.) Very Important – Please attach copies of organization By-Laws and a list of the Board of Directors M APP DO (1/08) Page 2 of 4 This application does not bind you nor us to complete the insurance, but it is agreed this form will be the basis of the contract should a policy be issued. This form will be attached to and become a part of this policy. ANY FRAUD WARNINGS CONTAINED IN THIS APPLICATION DO NOT APPLY TO NEBRASKA OR VERMONT APPLICANTS. FRAUD 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. FRAUD WARNING (APPLICABLE IN COLORADO): 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 policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder 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. FRAUD WARNING (APPLICABLE IN TENNESSEE AND WASHINGTON): It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. FRAUD WARNING (APPLICABLE IN VIRGINIA): It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. FRAUD WARNING (APPLICABLE IN THE STATE OF NEW YORK): 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. Probation Program: The Mental Health Risk Retention Group has a probation program for the benefit of its insureds which it believes is unique in the behavioral healthcare liability insurance market. When in the judgment of management an insured has adverse loss experience sufficient to justify nonrenewal, the insured may be placed on probation for one year rather than being nonrenewed. As part of probation an insured may be required to pay a premium surcharge and/or participate in a loss prevention program at its expense. This probation program is more fully described in the Company’s current confidential private offering memorandum available on the Company’s website at www.MHRRG.com. By signing this application, the undersigned represents that he or she agrees to the terms of the probation program as described in the offering memorandum. SIGNATURE: TITLE: (Must be signed by the Executive Director) DATE: (Please print or type name) M APP DO (1/08) Page 3 of 4 IOWA LICENSED AGENT: (Applicable in Iowa Only) PRODUCER: Will you make the surplus lines filing for this policy? ___Yes ___No Your Surplus Lines License Number _________________( ) M APP DO (1/08) Page 4 of 4
