D&O and Crime

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This is an application for D&O and Crime Insurance Coverage. Please note that the D&O is written on a claims-made policy, which, subject to its provisions, applies only to any Claim first made against the Insureds during the Policy Period. No coverage exists for Claims first made after the end of the Policy Period unless, and to the extent, the Extended Reporting Period applies.

Applying for:*

Directors' & Officers' Liability Crime & Fidelity

Submitting Broker

Submitting Broker Name*

Is broker properly licensed to produce this insurance?*

Yes No

Broker / Agency Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Broker Telephone Number*

Broker Email*

Applicant Non-Profit Association Information

Association Name*

Mailing Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Physical Address same as Mailing Address?*

Yes No

Physical Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Telephone*

Email Address*

Fax Number*

Association Type*

Please describe Association Type*

Property Manager Information

Does Entity have a Property Manager?

Yes No

Company Name

Mailing Address

Address Line 1

Address Line 2

City

State

ZIP Code

Telephone

Fax Number

Website

Association Liability (D&O) Underwriting Information

Proposed Effective Date

Date Association Established

# of Units in the Entity Currently Built

Is association still being developed?

Yes No

If yes, date completion expected

Total Number of Units at Build-Out

Name of the Developer

Does the Developer have more than 50% representation on the Board of Directors

Yes No

Commercial Occupancy? (other than the office of the Property Manager)

Yes No

If yes, percentage of commercial occupancy

Describe the type of Other Commercial Occupancy

Are any of the units part of a Rental Pool?

Yes No

If yes, what percentage of units participate?

Does the association have ARMED security services or an ARMED neighborhood watch person?

Yes No

Does the association have any of the following exposures? Please note that the association may not be eligible for the program and/or additional underwriting information may be required.

Nightclub/Bar Liquor Store Church Daycare School Hotel Airstrip/Hangars Government/Political Offices Hospitals/Healthcare Clinics/Centers (other than doctor's offices) Water/Sewage Treatment None

Does the Entity have a Positive Fund Balance?
If the fund balance is negative, please email financials and an explanation to commercial@orchidinsurance.com.

Does the Entity have a Positive Fund Balance?

Yes No

Has the association been in receivership or filed for bankruptcy in the last 3 years?

Yes No

Has there been an assessment increase or special assessment in the last 12 months or pending?

Yes No

If yes, what percentage was assessment increase?

Total amount of special assessment

Are greater than 20% of unit owners more than 90 days delinquent on association dues?

Yes No

If yes, what percentage?

Have any government fines or fees been assessed in the last 2 years?

Yes No

Is the Average Unit Value in excess of $1,000,000?

Yes No

Is the association an “Over 55” Community?

Yes No

Does the association own and/or manage any Amenities or Recreational Facilities such as Sport Courts, Pools/Spas, Lakes/Ponds, Playgrounds, Fitness Rooms, Community Centers, Golf Courses, Docks, Marinas or Vacant Land?

Yes No

How many of the following Amenities or Recreational Facilities does the association own and/or manage?

# of Sport Courts

# of Pools/Spas

# of Lakes/Ponds

# of Playgrounds

# of Fitness Rooms

# of Community Centers/Rooms

# of Golf Courses

# of Docks

# of Diving Boards

# of Pool Slides

# of Marinas

If Marina exists, are fuel services provided?

Yes No

If vacant land, square footage

Does the association provide or contract with a third party to provide beachfront or on water activities (i.e. parasailing, snorkeling, scuba)?

Does the association provide or contract with a third party to provide beachfront or on water activities

Yes No

If yes, please describe

Is there an association sponsored swim team?

Yes No

Describe any other Amenities/Recreation

Are any of the above open to the public?

Yes No

Expiring D&O Insurance Information (if applicable)

Expiring Insurance Company

Policy Period (start and end dates)

Limit

Deductible

Premium

D&O Desired Limits/Options

$1,000,000 aggregate limit of liability each policy year/$1,000,000 defense limit $2,000,000 aggregate limit of liability each policy year/$2,000,000 defense limit $3,000,000 aggregate limit of liability each policy year/$3,000,000 defense limit Other (Up to $5,000,000 available. Financials required for limits exceeding $3,000,000)

Define Desired Limits/Options

D&O Liability Loss/Claim History

In the past three years, has a claim been made, or is a claim now pending against, the Entity or any person in his or her capacity as a director, officer, trustee, employee, volunteer of the Entity?

Claim against entity?

Yes No

Please provide details of each claim by emailing commercial@orchidinsurance.com

Are any of the persons or entities to be insured under the policy responsible for or has knowledge of any Wrongful Act or fact, circumstance or situation which s(he) has reason to suppose might result in a future claim?

Wrongful act

Yes No

Please provide details of each responsive claim by emailing commercial@orchidinsurance.com

It is agreed by all concerned that if any of the persons or entities to be insured under the policy are responsible for or has knowledge of any Wrongful Act, fact, circumstance, or situation not described above, any Claim subsequently emanating therefrom shall be excluded from coverage under the proposed insurance as to such persons or entities. Such responsibility or knowledge shall not be imputed to any other persons or entities to be insured under the policy for the purpose of determining the availability of coverage.

Has any Directors’ & Officers’ Insurance, or other form of insurance similar to the proposed Policy, on behalf of the Entity been declined, canceled or not renewed? (Question is not applicable in the state of Missouri)

Insurance denied, cancelled, not renewed

Yes No

Please provide details of each responsive claim by emailing commercial@orchidinsurance.com

Crime & Fidelity Underwriting Information

Proposed Effective Date

Date Association Established

Total Number of Individuals who are Authorized to Handle Funds

Note: Property Manager = 1

Crime - Internal Controls & Procedures

How often does the Association have a Financial Statement prepared?

Who prepares the Financial Statement?

Please describe who prepares the Financial Statement

What is the scope of the Financial Statement?

Audit with opinion of Auditing Firm Review Compilation

Is a Countersignature required on all checks issued by the applicant?

Yes No

in excess of

Does the Association utilize a positive pay* service with their bank?
*Positive pay is a service whereby the association electronically shares its check register of all written checks with the bank. The bank therefore will only pay checks listed in that register, with exactly the same specifications as listed in the register (amount, payee, serial number, etc.) This system dramatically reduces check fraud.

Positive Pay

Yes No

Are Bank Accounts Reconciled by someone not authorized to deposit or withdraw therefrom?

Reconciled not authorized

Yes No

If "no", provide name, position and equity interest in Applicant of any reconcilers who may deposit or withdraw

Does the Property Manager have discretionary authority over the association's reserve fund?

Property Manager discretionary authority

Yes No

If yes, up to what limit?

Does the Board of Directors review bank statements and reserve fund balance at least quarterly?

Board of Directors review bank statements

Yes No

Crime - Prior Crime & Fidelity Insurance Information

Current Insurance Company

Policy Period (start and end dates)

Limit

Deductible

Premium

Crime - Loss/Claim History

Any Loss History for the Past 3 Years?

Yes No

Date Loss Discovered

Type of Loss

Amount of Loss

Amount Recovered from Insurance

Describe Circumstances of Loss and Action Taken to Help Prevent Repetition

Crime & Fidelity Coverage and Desired Limits/Deductibles *Note: Some limits/deductible combinations may not be available

Select the desired coverages

Employee Theft Forgery or Alteration Theft Disappearance & Destruction (Premises & Transit; Includes Robbery & Safe Burglary) Computer Fraud & Wire Transfer

Employee Theft Limit

Employee Theft Deductible

Forgery or Alteration Limit

Forgery or Alteration Deductible

Theft Disappearance & Destruction Limit

Theft Disappearance & Destruction Deductible

Computer Fraud & Wire Transfer Limit

Automatically matches Employee Theft Limit

Computer Fraud & Wire Transfer Deductible

Automatically matches Employee Theft Deductible

Application Signature

The undersigned declares that to the best of his/her knowledge the statements set forth herein are true and correct. Signing of this Application does not bind the undersigned to complete the insurance, but it is agreed that this Application shall be the basis of the contract should a Policy be issued. It is agreed that this Application, a copy of which will be attached to the proposed Policy, and any materials submitted or required (which shall be maintained on file by the Insurer and be deemed attached as if physically attached to the proposed Policy), are true and are the basis of the proposed Policy and are to be considered as incorporated into and constituting a part of the proposed Policy. If between the date of this Application and the proposed effective date of the Policy there is a material change in the condition of the Entity or occurrence of an event which could substantially change the underwriting evaluation of the Applicant, then the Applicant must notify Continental Casualty Company. Upon receipt of such notice, Continental Casualty Company reserves the right to modify the final terms and conditions of the proposed policy upon review of the information received in satisfaction of the aforementioned conditions. In addition, any outstanding quotations may be modified or withdrawn at the sole discretion of the Insurer.

The undersigned declares that the employees of the applicant have all, to the best of the applicant’s knowledge and belief, while in the service of the applicant, always performed their respective duties honestly, There has never come to its notice or knowledge, except as stated herein, any information which in the judgment of the applicant indicates that any of the said employees are dishonest. Such knowledge as any officer signing for the applicant may now have in respect to his or her own personal acts or conduct, unknown to the applicant, is not imputable to the applicant.

It is understood that the first premium upon the policy applied for, and subsequent premiums hereon, are due at the beginning of each premium period, that the company is entitled to additional premiums because of any unusual increase in the number of employees and that the applicant agrees to pay all such premiums promptly.

Signature of Authorized Association Representative

Name & Title of Authorized Association Representative

Applicable in AL, AR, DC, LA, MD, NM, RI and WV:

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 and denial of insurance benefits. *Applies in ME Only.

Applicable in CO:

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.

Applicable in FL and OK:

Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony (of the third degree)*. *Applies in FL Only.

Applicable in KS:

Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act.

Applicable in KY, NY, OH and PA:

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* (not to exceed five thousand dollars and the stated value of the claim for each such violation)*.

*Applies in NY Only.

Applicable in ME, TN, VA and WA:

Applicable in NJ:

Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

Applicable in OR:

Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact may be violating state law.

Applicable in PR:

Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances [be] present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years.

Reminder: You must email financials for D&O Desired Limits/Options exceeding $3,000,000 to commercial@orchidinsurance.com.

Reminder: You must email details of each claim that's been made or is pending against Entity or any person in his or her capacity as a director, officer, trustee, employee, volunteer of the Entity to commercial@orchidinsurance.com.

Reminder: You must email details of each responsive claim that any of the persons or entities to be ensured under the policy is responsible for or has knowledge of any Wrongful Act or fact, circumstance or situation which s(he) has reason to suppose might result in a future claim to commercial@orchidinsurance.com.

Reminder: You must email financials and an explanation for the Entity's negative fund balance to commercial@orchidinsurance.com.

Reminder: You must email details of each responsive claim of Directors' & Officers' Insurance, or other form of insurance similar to the proposed Policy, on behalf of the Entity having been declined, canceled or not renewed to commercial@orchidinsurance.com.