ࡱ>  1()!q` PbjbjqPqP }::*&* * * * * * * d v-v-v-&./ r,0fHAHAHAHAOCEGNNNN=N_p$=shu^ q* IC@OCII q* * HAHAq&SMSMSMIv* HA* HANSMINSMSM* * SMHA0 O8v-J SMsM$q<rSMv7LvSMv* SM KH>H,SMH$HKHKHKH q qLdKHKHKHrIIII ",d , * * * * * *  PRIVATE  RENEWAL PROPOSAL FORM Non-Profit Corporations DIRECTORS' & OFFICERS' LIABILITY & CORPORATE REIMBURSEMENT INSURANCE This is a Proposal Form for an insurance policy relating to Claims made against the Directors and Officers and reported to the Insurer during the Policy Period. Please note: all of the following questions must be answered and all required attachments specified in Section 6 must be provided words and expressions appearing in bold italics in this proposal form are defined in the policy wording. 1. GENERAL INFORMATION a) Name of the Non-Profit Corporation:  FORMTEXT       b) Address:  FORMTEXT        FORMTEXT       Postal Code:  FORMTEXT       Phone:  FORMTEXT       Fax:  FORMTEXT       c) Total Budget for next twelve (12) months:  FORMTEXT       d) Please enumerate the sources of income and the percentage of total income:  FORMTEXT        FORMTEXT       %  FORMTEXT        FORMTEXT       %  FORMTEXT        FORMTEXT       % 2. POLICY INFORMATION a) Policy Number :  FORMTEXT       b) Expiry Date :  FORMTEXT       c) Current Limit :  FORMTEXT       d) Limit requested :  FORMTEXT       (actual limit to be provided will be indicated in the Policy Declarations) 3. CORPORATE INFORMATION a) Is the Corporation currently or has it, during the past twelve (12) months, been in arrears in its payments of monies payable to Revenue Canada or the provincial ministries of revenue (including source deductions, G.S.T and P.S.T) ? Yes  FORMCHECKBOX  No  FORMCHECKBOX  - 2 - b) Is the Corporation currently or has it, during the past twelve (12) months, been in breach of any of its debt covenants, loan agreements or contractual obligations, or does it anticipate any such breach occurring within the next twelve (12) months ? Yes  FORMCHECKBOX  No  FORMCHECKBOX  c) Has the Corporation changed its outside accountant or external legal counsel during the past year ? Yes  FORMCHECKBOX  No  FORMCHECKBOX  d) Is the Corporation or any of its Subsidiaries currently, or has it at any time during the past year: (i) sought protection under the "Companies' Creditors Arrangement Act" (Canada), or (ii) made a commercial proposal under Part III of the Bankruptcy and Insolvency Act (S.C. 1992, Ch. 27), or (iii) sought protection under "Chapter 11" of the U.S.C. (United States Bankruptcy Code), or does it anticipate seeking such protection or making such a proposal within the next twelve (12) months ? Yes  FORMCHECKBOX  No  FORMCHECKBOX  (If the answer to any of the above questions is Yes, please provide full details.) 4. ANNOUNCED OR CONTEMPLATED CHANGES a) Have there been any changes in the Directors or Officers in the past twelve (12) months? Yes  FORMCHECKBOX  No  FORMCHECKBOX  b) Does the Corporation have under consideration at the present time or does it contemplate any acquisitions, divestitures, tender offers or mergers? Yes  FORMCHECKBOX  No  FORMCHECKBOX  (If the answer to any of the above questions is Yes, please provide full details.) 5. NOTICE Identify the Officer of the Corporation designated to receive all notices from the Insurer concerning this insurance: NAME (Please print) TITLE 6. ATTACHMENTS IMPORTANT: PLEASE SUBMIT ONE COPY OF EACH OF THE FOLLOWING DOCUMENTS WHICH WILL BE CONSIDERED TO BE PART OF THIS PROPOSAL: a) Latest annual report including financial statements; b) Latest interim financial statement; c) By-laws of the Corporation; d) List of proposed Insured persons (complete Appendix A); e) List of Committees (complete Appendix B); f) List of Subsidiaries (complete Appendix C); Note: With respect to items d) & f) above, notwithstanding the contents of the appendices or lists submitted and subject to the terms and conditions of the proposed insurance, coverage will only be afforded to those individuals and companies that fit within the definitions of Director and Officer and Subsidiary, unless otherwise agreed to by the Insurer and specifically endorsed onto the policy. - 3 - 7. WARRANTIES AND SIGNATURE THE APPLICANT DOES HEREBY PROVIDE THE FOLLOWING WARRANTIES TO THE INSURER: a) The undersigned Director of the Corporation is duly authorized to make representations and to sign on behalf of all of the Directors and Officers and the Corporation and declares that the statements herein are true and complete. b) The undersigned Director of the Corporation declares that the financial statements submitted with this proposal form are representative of the current financial position of the Corporation including its Subsidiaries . c) Signing of this proposal form does not bind the Insurer to complete the insurance, but it is agreed that this proposal form will be the basis of the contract should a policy be issued, and that this proposal form will be attached to and become a part of such policy, if issued. The Insurer is hereby authorized to make any investigation and inquiry in connection with this proposal as it may deem necessary. d) It is warranted that the particulars and statements contained in the proposal form for the policy and any materials submitted herewith (which will be retained on file by the Insurer and which will be deemed attached hereto, as if physically attached hereto), are the basis for the policy and are to be considered as incorporated into and constituting a part of the policy. e) It is agreed that in the event that there is any material change in the answers to the questions contained herein prior to the effective date of the policy, the Corporation will notify the Insurer and, at the sole discretion of the Insurer, any outstanding quotations may be modified or withdrawn. N.B. COVERAGE CANNOT BE BOUND UNLESS THIS PROPOSAL FORM HAS BEEN DULY COMPLETED AND DULY SIGNED AND DATED. Corporation Name of Chairman of the Board or President (in block letters) Date Signature of Chairman of the Board or President - 4 - APPENDIX "A" LIST OF INSURED PERSONS PRIVATE  DIRECTORS OFFICERS  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        - 5 - APPENDIX "B" LIST OF COMMITTEES PRIVATE  NAME OF COMMITTEE BRIEF DESCRIPTION OF FUNCTIONS  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       APPENDIX "C" SUBSIDIARIES  Latest Fiscal Year End Name Acquisition Date % Owned Nature of Activities Location Net Worth Total Assets Net Income   FORMTEXT        FORMTEXT     &?@  & ' ( ) ĭ՝}}mZmZmZmZmI!hQ>*@CJOJQJmH sH $hQ56@CJOJQJmH sH hQ@CJOJQJmH sH hQ5@OJQJmH sH  hQ5>*@OJQJmH sH hQ@CJOJQJmH sH -jGhQ@CJOJQJUmH sH !hQ@CJOJQJmH sH *jhQ@CJOJQJUmH sH 'jhQ@CJOJQJUmH sH  '@( * + YYO $ `'*$a$6$ Y`0h8p @ xHP X !(#$x*$a$6$ Y`0h8p @ xHP X !(#$*$a$4$ Y`0h8p @ xHP X !(#$*$a$$*$a$ N) * + 6 @ B H N t ӯӞ‹ӯudKu4ud-jhQ>*@CJOJQJUmHnHu0jHhQ>*@CJOJQJUmH sH 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