D & O LIABILITY

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Name of Company	*
Company Registration Number	*
Contact Name *	email address *	Phone Number
Main Office Address
	Post Code
Are the shares solely owned by the director? if No. please provide details

Company Activity
Turnover for the last financial year
Net Profit for the last financial year
Shareholder funds shown in last audited accounts
Does the Company have any assets or subsidiaries in, or turnover generated from the USA or Canada?
Have claims been made against any past or present Director or Officer of the Company or its Subsidiaries
Is the proposer aware, after enquiry, of any circumstance which may give rise to a claim?
Is cover required for claims against the Company in respect of Employment Practices Liabilty claims?
If YES, please confirm the number of employees
Full-time Part-time
Do you currently hold D&O or EPL?
If Yes, please provide the following details
Current Renewal Date	Insurers Name
Indemnity Limit	Policy Excess	Last Premium
Please state the limit of Indemnity you require

* = required information

Authorised & regulated by the Financial Services Authority Firm Reference Number 126179