BY COMPLETING THIS APPLICATION YOU ARE APPLYING FOR COVERAGE WITH
FEDERAL INSURANCE COMPANY (THE “COMPANY”).

NOTICE:  THE LIABILITY COVERAGE SECTIONS OF THIS POLICY (WHICHEVER ARE PURCHASED) PROVIDE CLAIMS MADE COVERAGE, WHICH APPLIES ONLY TO "CLAIMS" FIRST MADE DURING THE "POLICY PERIOD", OR AN APPLICABLE 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.  IN NO EVENT WILL THE COMPANY BE LIABLE FOR "DEFENSE COSTS" OR THE AMOUNT OF ANY JUDGMENT OR SETTLEMENT IN EXCESS OF THE APPLICABLE LIMIT OF LIABILITY.  READ THE ENTIRE APPLICATION CAREFULLY BEFORE SIGNING.

APPLICATION INSTRUCTIONS:

•	Whenever used in this Application, the term “Applicant” means the Organization applying for this insurance and all of its subsidiaries, unless otherwise stated.
•	Include all requested underwriting information and attachments.

I.	REQUESTED COVERAGE:

Coverage Sections Requested	Limit of Liability Requested	
	Directors & Officers Liability and Entity Liability and Employment Practices Liability		$1,000,000 or  $2,000,000 or  Other:  		
	Fiduciary Liability		$100,000 or  $250,000 or $500,000	

II.	GENERAL INFORMATION:

1.	Name of Applicant:  	

2.	Applicant’s Principal Address:  	

City:  	  State:  	  Zip Code:  	

3.	State of incorporation:  	  Date established:  	  Web site address:  	

4.	Executive officer authorized to receive notices and information regarding the proposed policy:

Name:  	  Title:  	

Contact’s e-mail address:  	  Phone:  	  Fax:  	

5.	Nature of the Applicant’s business:  	

6.	Does the Applicant now have recognized tax-exempt status under the U.S. Internal Revenue Code?	 Yes    No

7.	(a)	Does the Applicant have any subsidiaries or control any other entity or organization for which coverage is requested?	 Yes    No
If Yes, please attach a description of the operations, ownership, and the tax status of each such entity.
(b)	Does the Applicant or any subsidiary render any professional services, including but not limited to conducting any standard setting, accrediting, credentialing or licensing activities, for others for a fee?	 Yes    No
(c)	Does the Applicant sponsor any insurance programs for members?	 Yes    No

If Yes to (b) or (c) of Question 7, please describe:  	

8.	(a)	Applicant’s most recent year end Revenue:  	

(b)	Number of Compensated Employees:  	  Number of Volunteers:  	

9.	Does the Applicant have written procedures in place regarding:
(i)	Equal Opportunity Employment:	 Yes    No
(ii)	Anti - Discrimination:	 Yes    No
(iii)	Anti - Sexual Harassment:	 Yes    No
If No to any of the above, please attach a full explanation.

10.	In the next 12 months (or during the past 18 months) is the Applicant contemplating (or has the Applicant completed or been in the process of completing):
(a)	Any reorganization or arrangement with creditors under federal or state law?	 Yes    No
(b)	Any branch, location, facility, or office closings, consolidations or layoffs?	 Yes    No
If Yes to any part of Question 10, please attach an explanation to this Application.

11.	Has the Applicant or any person proposed for coverage been the subject of, or involved in, any of the following in the past five years:
(a)	Anti-trust, copyright or patent litigation?	 Yes    No
(b)	Any criminal actions?	 Yes    No
(c)	EEOC, NLRB or other similar administrative proceeding?	 Yes    No
(d)	Employment-related civil suit?	 Yes    No
(e)	Any action or civil suit brought against it by a customer, client, vendor, supplier or third party alleging sexual harassment, discrimination or civil rights violations?	 Yes    No
If Yes to any of the above, attach a full description of the details.

12.	Other than those identified in your response to Question 11, has any claim been brought at any time during the last 5 years against: (i) any Applicant or (ii) any proposed insured individual in his or her capacity as a director, officer or trustee of any entity?	 Yes    No
If Yes, please attach a full description of the details.

III.	FIDUCIARY INFORMATION:

1.	Please complete the following information regarding the Applicant’s employee benefits plan(s).

Plan name
(do not include health and
welfare plans)	Type of
plan*	Plan assets
(current year)	Underfunded by more than 25%? (DBP only)	Number of plan
participants	

		

		

		

		
*Types of Plans:	Defined Contribution Plan = DCP	Excess Benefit Plan or Top Hat Plan = EBP
Defined Benefit Plan = DBP

2.	Does the Applicant handle any investment decisions in-house?	 Yes    No

If Yes, please describe:  	

3.	Does each of the Applicant’s employee benefit plans conform to the standards of eligibility, participation, vesting and other provisions of ERISA?	 Yes    No

If No, please explain:  	

4.	Past activities:
(a)	Has any fiduciary been:
(i)	accused of, found guilty of, or held liable for a breach of trust?	 Yes    No
(ii)	convicted of criminal conduct?	 Yes    No
(b)	Has there been any assessment of fees, fines or penalties against any of the Applicant’s employee benefit plans under any voluntary compliance resolution program or similar voluntary settlement program administered by the IRS, DOL or other government authority?	 Yes    No
If Yes, to any of the above, please attach a full description of the details.

IV.	PRIOR INSURANCE:

1.	Please complete the chart below:
•	Indicate those coverages currently purchased; and
•	Attach a copy of all applications submitted to the current insurer or any prior insurers:

Liability Coverage	Yes	No	Insurer	Limit	Retention	Policy Period	
a.	Directors & Officers And Entity Liability

	
		
$		

b.	Employment Practices Liability
					$						
c.	Fiduciary Liability					$						

2.	IMPORTANT: The Company will be relying upon the declarations and statements contained in such prior application(s) and the Applicant understands and agrees those declarations and statements shall be considered to be incorporated in, and form part of any policy issued by the Company.

V.	PRIOR KNOWLEDGE:

The Applicant must complete the Prior Knowledge Statement below:
	If the Applicant answered ”No” to any Liability Coverage listed above; or
	If the Applicant is requesting larger limits in Section I, REQUESTED COVERAGE, than are currently purchased as indicated in Item IV (1) of this Application.

The Applicant understands and agrees the Prior Knowledge Statement below applies to those liability coverage types for which no coverage is currently maintained; and to those liability coverages for which the Applicant is requesting limits of liability greater than currently maintained.

PRIOR KNOWLEDGE STATEMENT: No person or entity proposed for coverage is aware of any fact, circumstance or situation 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 liability coverages for which the Applicant does not currently maintain insurance, or within any of the larger limits of liability sought by the Applicant, except:  None  or  	

Without prejudice to any other rights and remedies of the Company, the Applicant understands and agrees that if any such fact, circumstance, or situation exists, whether or not disclosed above, any claim or action arising from any such fact, circumstance, or situation is excluded from coverage under the proposed policy, if issued by the Company.

VI.	MATERIAL CHANGE:

If there is any material change in the answers to the questions in this Application before the policy inception date, the Applicant must immediately notify the Company in writing, and any outstanding quotation may be modified or withdrawn.

VII.	DECLARATIONS, FRAUD WARNINGS AND SIGNATURE:

The Applicant's submission of this Application does not obligate the Company to issue, or the Applicant to purchase, a policy.  The Applicant will be advised if the Application for coverage is accepted.  The Applicant hereby authorizes the Company to make any inquiry in connection with this Application.

The undersigned authorized agent of the person(s) and entity(ies) proposed for this insurance declares that to the best of his or her knowledge and belief, after reasonable inquiry, the statements made in this Application and in any attachments or other documents submitted with this Application are true and complete.  The undersigned agrees that this 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 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 Maryland 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 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 Virginia 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.

Date	Signature*	Title

				Chief Executive Officer/Executive Director

*This Application must be signed by the Chief Executive Officer or Executive Director of the Organization acting as the authorized representative of the person(s) and entity(ies) proposed for this insurance.

Please attach a copy of the following for every Applicant seeking coverage:
	Most recent CPA prepared financial statements or 990 Tax Form

Produced By:
Agent:  Robert J. Cannon	Agency:  Gorges & Company
Agency Taxpayer ID or SS No.:  52-0624827	Agent License No.:  RAI00033175
Address (Street, City, State, Zip):  2345 York Road, Timonium, MD 21093