Travelers Insurance Company of Canada	Public Company Multi-Coverage Application

Certain information requested in this application is for claims-made coverage sections. If issued, the claims made coverage sections of the policy cover only claims made against insureds during the policy period or any applicable extended reporting period. Unless defence outside limits coverage is elected, defence expenses will reduce, and may exhaust, the limit of insurance, except as otherwise required by the law of the province of Québec, and the Insurer will not be liable for defence expenses or the amount of any judgment or settlement after the exhaustion of the limit of insurance. If defence outside limits coverage is elected, payment of defence expenses will not reduce the limit of insurance, except as respects claims brought and maintained in the United States of America.

CONTACT INFORMATION

“Applicant” means all entities, including subsidiaries, for which coverage is requested.

Name of Applicant:
Address:
Web Address:	Telephone Number:

GENERAL RISK INFORMATION

1.	In the next 12 months is the Applicant contemplating, or during the past 12 months has the Applicant completed or been in the process of completing, the following:
a. Any acquisition, tender offer, merger, consolidation, or divestiture; or purchase or sale of assets exceeding 30% of consolidated assets?	Yes No
b. Any offers (including tender offers) or negotiations to purchase 5% or more of any class of voting stock?	Yes No
c. A private placement of securities?	Yes No
d. Any branch, location, facility, office, or subsidiary closings, consolidations, or layoffs?	Yes No
If any part of question 1. is answered “Yes”, attach an explanation, including the timing, the essential terms of the event, the arrangement, the impact on employee base, and the surrounding circumstances.

2.	List and describe any subsidiaries or affiliated companies for which coverage is requested, and attach an organization chart. (Check here if not applicable: )
Name	Percentage Owned	Year Started	Description of Operations	Entity Type*
%
%
%
%
*FP = For-Profit (other than Partnership); NP = Non-Profit; GP = General Partnership; LP = Limited Partnership; LLC = Limited Liability Company

3.	List locations and corresponding employee numbers:
Country	Number of Locations	Full-Time* Employees	Part-Time** Employees	Independent Contractors
Canada
United States of America
*Including leased employees **Including seasonal, temporary, and volunteer employees

INSURANCE INFORMATION

4.	Provide details about the Applicant’s requested and current insurance coverage. Note: Coverage checkbox must be selected to reveal coverage specific questions.
Coverage Requested	Current Limit	Current Retention	Current Premium	Current Carrier	Date First Purchased (dd/MON/yyyy)
Directors, Officers, and Organization Liability	$	$	$
Employment Practices Liability	$	$	$
Option: Third Party Claim	$	$	$
Fiduciary Liability	$	$	$
Crime	$	$	$
Option: Employee Theft of Client Property	$	$	$
Option: Social Engineering	$	$	$
Kidnap and Ransom	$	$	$
CyberRisk	$	$	$
Identity Fraud Expense Reimbursement	$	$	$

5.	Requested effective date:	(dd/MON/yyyy)

6.	Type of Defence Coverage requested for Liability Coverages:	Duty to Defend	Reimbursement

7.	Would you like options for shared limits?	Yes No

DIRECTORS, OFFICERS, AND ORGANIZATION LIABILITY INFORMATION

1.	Has any insurer declined, cancelled or refused to renew the Applicant’s Directors and Officers Liability Coverage?	Yes No
If “Yes”, please attach an explanation.

LOSS INFORMATION — DIRECTORS, OFFICERS, AND ORGANIZATION LIABILITY

2.	As respects the Liability Coverages requested in this Application, has any person or entity proposed for this insurance been a party to, or subject of, any administrative or regulatory proceedings or civil or criminal charges, hearings, demands, or lawsuits during the past 3 years, whether or not insured, including any such matter involving securities, security holders, creditors, antitrust or fair trade law, copyright or patent law, ERISA, discrimination, harassment, or employment-related matters?	Yes No
If “Yes”, attach a description of the details including date, nature of claim, amount paid for defence, amount sought or paid for damages, whether covered by insurance, corrective procedures implemented, and current status.

REQUIRED ATTACHMENTS — DIRECTORS, OFFICERS, AND ORGANIZATION LIABILITY

3.	As part of this Application, submit the following documents:
a. Most recent audited financial statements or public documents filed by the Applicant with the Ontario Securities Commission or any similar federal, provincial, territorial, local, or regulatory agency in the past 18 months.
These documents, and the representations and facts they contain, are made a part of this Application, whether such documents are physically delivered to Travelers Insurance Company of Canada by the Applicant or are obtained by Travelers Insurance Company of Canada from any public source, including the Internet.

EMPLOYMENT PRACTICES LIABILITY INFORMATION

1.	Does Applicant have employees located in the United States of America?	Yes No
If “Yes”, specify number of employees located in:	California	New Jersey	West Virginia

2.	Total number of employees compensated over $100,000 annually:

3.	What percent of the Applicant’s workforce is unionized?	%

4.	Provide the employee turnover figures for the past 2 years:
Terminations	Year 20	Year 20
Voluntary
Involuntary (excluding layoffs/downsizing)
Layoffs/Downsizing

5.	Are human resources personnel or employment counsel consulted prior to every termination?	Yes No

6.	Does the Applicant have written guidelines, policies, or procedures related to the following:
a. Discrimination?	Yes No
b. Sexual and other workplace harassment?	Yes No
c. Retaliation?	Yes No
d. Reporting, investigating, and resolving employee complaints?	Yes No
e. Accommodating disabled employees?	Yes No
f. Equal opportunity employment?	Yes No

7.	Are employees required to acknowledge receipt of the above guidelines, policies, and procedures?	Yes No

8.	Has employment counsel reviewed the above guidelines, policies, and procedures?	Yes No

9.	Does the Applicant:
a. use employment applications?	Yes No
b. document employee performance?	Yes No
c. conduct human resources training for management employees?	Yes No

THIRD PARTY CLAIM COVERAGE INFORMATION

10.	What percentage of the Applicant’s workforce has exposure to or interaction with the public (i.e.: customers, clients, suppliers, vendors, etc.):	%

11.	Does the Applicant have written policies and procedures outlining employee conduct, including handling complaints from the general public, customers, clients, vendors, or other third parties?	Yes No

12.	Does the Applicant have a formal customer service or public interaction training program for its employees?	Yes No
If “Yes”, are employees who interact with the public required to attend and satisfactorily complete this program?	Yes No

13.	Does the training include a no tolerance workplace harassment and discrimination training program?	Yes No

LOSS INFORMATION — EMPLOYMENT PRACTICES LIABILITY

14.	Have any employment-related claims or administrative, criminal, or regulatory proceedings, charges, hearings, demands, or lawsuits been made against the Applicant or any person proposed for this insurance during the past 3 years, whether or not insured, including claims involving employees or independent contractors?	Yes No
If “Yes”, attach a description of the details including date, nature of claim, amount paid for defence, amount sought or paid for damages, whether covered by insurance, corrective procedures implemented, and current status.

REQUIRED ATTACHMENTS — EMPLOYMENT PRACTICES LIABILITY

15.	As part of this Application, submit the following documents:
a. Employee handbook, if Applicant has 500 or more employees
b. Most recent EEO-1 report, if Applicant has 1,000 or more U.S. employees

FIDUCIARY LIABILITY INFORMATION

1.	List the plans for which the Applicant is requesting coverage:
Full Plan Name	Plan Type*	Current Asset Value	Latest FYE Annual Contributions	Current # of Participants	Plan Status**
$	$
$	$
$	$
*DC = Defined Contributions; DB = Defined Benefit; E = ESOP; W = Welfare Benefit Plan; O = Other (attach explanation) ** A = Active; F = Frozen; S = Sold; T = Terminated

2.	List the firms the Applicant has hired to provide the following services:
Plan Administrator	Legal Counsel	Actuary	Investment Advisor

3.	Does the Applicant’s plan fiduciaries and advisors adhere to written investment guidelines?	Yes No

4.	Are all plans in compliance with the Pension Benefits Standards Act, 1985, or any similar provincial statute, or in the United States, ERISA?	Yes No

5.	In the next 12 months will any of the following occur, or have any of the following occurred during the past 24 months, for any plan for which coverage is requested:
a. An amendment that results in a reduction of benefits?	Yes No
b. A merger with another plan, termination, or sale?	Yes No
c. An investigation by any federal or provincial benefit regulator or any similar foreign agency?	Yes No
d. A filing for an exemption from a prohibited transaction?	Yes No
e. Any outstanding or delinquent contributions?	Yes No
If any part of question 5. is answered “Yes”, attach an explanation.

6.	If any plan is a defined benefit plan, has such plan: (Check here if not applicable: )
a. not been certified by an actuary to be adequately funded in accordance with applicable common or statutory law in Canada, the United States of America, or any provincial, territorial, local, state, or foreign jurisdiction?	Yes No
b. been converted into a cash balance plan or is any such conversion expected in the next 12 months?	Yes No
If any part of question 6. is answered “Yes”, attach an explanation.

LOSS INFORMATION — FIDUCIARY LIABILITY

7.	In the past 3 years, whether or not insured, has any plan, Applicant, or person proposed for this insurance been accused or found guilty of any criminal act or been accused of, found guilty of, or held liable for a breach of fiduciary duty, or a violation of ERISA, or any similar federal, provincial, territorial, state, local, or foreign law or have any ERISA-related claims, administrative or regulatory proceedings, charges, hearings, or demands been made?	Yes No
If “Yes”, attach a description of the details including date, nature of claim, amount paid for defence, amount sought or paid for damages, whether covered by insurance, corrective procedures implemented, and current status.

REQUIRED ATTACHMENTS — FIDUCIARY LIABILITY

8.	As part of this Application, submit the following documents:
a. Plan financial statements for defined benefit plans and self insured welfare plans.
b. Latest actuarial report for defined benefit plans and self insured welfare plans.
These documents, and the representations and facts they contain, are made a part of this Application, whether such documents are physically delivered to Travelers Insurance Company of Canada by the Applicant or are obtained by Travelers Insurance Company of Canada from any public source, including the Internet.

CRIME INFORMATION

1.	List all additional entities for which coverage is requested: Receipt of this information does not constitute an agreement that coverage will be provided to the listed entities.
Name of Entity	Description of Operations	Relationship to Applicant

2.	Indicate the total amount of cash inside the premises for all locations combined:	$

3.	Indicate the total amount of cash being transported by a messenger outside the premises for all locations combined:	$

4.	Are bank account statements reconciled at least monthly?	Yes No

5.	Does any employee other than the person responsible for reconciling bank accounts:
a. make deposits?	Yes No	b. make withdrawals?	Yes No	c. sign cheques?	Yes No

6.	Is countersignature of cheques required?	Yes No	If “Yes”, what is the dual signing limit?	$

7.	Is segregation of duties practiced in the following areas:
a. Inventory management?	Yes No	d. Oversight of blank cheque stock?	Yes No
b. Vendor approval?	Yes No	e. Cash, cheque and credit card receipts?	Yes No
c. Purchase order approval and payment?	Yes No	f. Wire transfer receipts and payment?	Yes No

8.	Is a physical count of inventory conducted at least annually?	N/A	Yes No

9.	Are periodic reviews of all unused or obsolete inventory (including raw materials and scrap metals) conducted?	N/A	Yes No

10.	Are inventory records computerized?	N/A	Yes No

11.	Is there a software security system in place to detect fraudulent computer usage by employees, agents, and outsiders?	Yes No

12.	Are the duties of computer programmers and computer operators separated?	Yes No

13.	Are passwords and access codes changed at regular intervals and when users are terminated?	Yes No

14.	Is dual authorization required for all wire transfers?	Yes No
If “Yes”, what is the average daily dollar volume of wire transfers?	$

15.	Are the same internal controls listed above imposed on all locations and entities (including foreign)?	Yes No

16.	Indicate if the Applicant has or performs any of the following: (Check all that apply.)
Business Practices/Policies	Physical Controls	Hiring/Screening Practices
Internal Audit Department	Security guards	Prior employment verification
Fraud policy	Messengers	Education verification
Code of ethics	Premises alarm systems	Credit check
Conflict of interest policy	Controlled premises access	Criminal background check
Confidential hotline / procedure for employees to report violations of policies	Other protection

17.	Indicate any of the following characteristics or exposures that apply to the Applicant’s business operations: (Check all that apply.)	N/A
Proprietary trading activity	Narcotics	Precious metals or gemstones
Managed assets of others	High unit, portable inventory	Art collection or other valuable collectibles
Care, custody and control of clients’ property	Computer chips	Warehousing operations
For every applicable characteristic or exposure above, provide details that quantify the exposure and briefly describe the controls in place to protect the Applicant from loss in a separate attachment.

SOCIAL ENGINEERING INFORMATION

18.	Does the Applicant make payments to third parties via a wire-transfer system?	Yes No
If “Yes”, how frequently are such payments made?

19.	Does the Applicant provide anti-fraud training, including social engineering, phishing, masquerading, and other fraud schemes, to all employees responsible for authorizing and executing payments or funds-transfer requests?	Yes No

20.	Does the Applicant verify all new vendors’ bank accounts by a direct call to the payment receiving bank prior to adding such banking information to the Applicant’s account payable system?	Yes No

21.	Does the Applicant confirm all change requests regarding vendor account information (including changes to bank account information, invoice changes, telephone or telefacsimile numbers, location, and contact information) by a direct call to the vendor using only the telephone number provided by the vendor before the change request was received?	Yes No

22.	Does the Applicant require that all such vendor change requests be approved by the supervisor of the individual who received the change request, before it is acted upon?	Yes No

23.	Does the Applicant accept payments or funds-transfer instructions from a client relating to a refund or repayment of goods, services, or funds held in the Applicant’s custody?	Yes No
If “Yes”, select the communication method by which such instructions are deemed acceptable: (Check all that apply.)
Telephone	E-mail	Text message
Telefacsimile (fax)	Mail	Other

24.	Does the Applicant confirm all such payments or funds-transfer instructions made by a client by a direct call to the client using only the telephone number provided by the client before the payment or funds transfer request was received?	Yes No

25.	Does the Applicant have custody or control over any funds or money belonging to any of its clients, including escrow or trust accounts?	Yes No
If “Yes”, describe the nature of the control or custody and oversight procedures associated with protecting such funds or money.

26.	Does the Applicant have procedures in place to verify the authenticity of any request for payment or funds-transfer received by an authorized individual from an internal company source (e.g., another employee, subsidiary, location, or department)?	Yes No
If “Yes”, describe the procedures:

27.	Does the Applicant require that any payment or funds transfer request made by an internal company source be approved by the supervisor of the individual who received the payment or funds transfer request, before it is acted upon?	Yes No

LOSS INFORMATION — CRIME

28.	Has the Applicant or any proposed insured sustained any crime-related losses in the past 3 years?	Yes No
If “Yes”, attach a description of the details including date, description of loss, amount of the loss, whether covered by insurance, corrective procedures implemented, and current status.

REQUIRED ATTACHMENTS — CRIME

29.	As part of this Application, submit the following documents:
Auditor’s letter to management on internal controls and management’s response if limit requested is $5,000,000 or greater.
b. Most recent annual financial statement if limit requested is $5,000,000 or greater.
c. If Employee Theft of Client Property Coverage is requested: (i) for blanket coverage, submit a specimen copy of contract used for all clients; or (ii) for contract-specific coverage, submit a copy of the entire contract including the section which details the work to be performed.

KIDNAP AND RANSOM INFORMATION

1.	Are any of the Applicant’s operations to be insured involved in the production of foodstuffs, beverages, or pharmaceuticals (including toothpaste, mouthwash, etc.)?	Yes No

2.	Does the Applicant own or operate, or seek coverage for any individual who will work or travel on, any ship, vessel, tug, barge, or rig?	Yes No

3.	Do directors, officers, or other employees of the Applicant travel outside Canada or the United States of America?	Yes No
If “Yes”, provide travel information for the past 12 months and estimates of the next 12 months.
City and Country of Destination	Number of Trips	Number of Individuals	Average Length of Trips

4.	Does the Applicant have any permanent locations outside Canada or the United States of America?	Yes No
If” Yes”, provide both the existing and anticipated foreign locations.
City and Country	Number of Locations	Type of Operation	Number of Employees

5.	Does the Applicant have security precautions to ensure an insured person’s safety when travelling outside Canada and the United States or America?	Yes No

6.	Does the Applicant have security precautions to ensure the safety of insured persons and premises permanently located outside Canada and the United States of America?	Yes No
If questions 5. or 6. are answered “Yes”, describe these security precautions:

INCIDENT OR LOSS INFORMATION — KIDNAP AND RANSOM

7.	Is the Applicant or any person proposed for this insurance aware of any fact, circumstance, situation, event, or act that reasonably could give rise to a claim under this coverage?	Yes No
If “Yes”, attach an explanation.
As respects the information required to be disclosed in response to the questions above, the proposed insurance will not afford coverage for any claim arising from any fact, circumstance, situation, event, or act about which any executive officer of the Applicant had knowledge prior to the issuance of the proposed policy, nor for any person or entity who knew of such fact, circumstance, situation, event, or act prior to the issuance of the proposed policy.

8.	Has the Applicant or any person proposed for this insurance been involved in a kidnapping, detention, hijacking, or extortion for ransom incident during the past 3 years?	Yes No
If “Yes”, attach a description of the details including date, description of loss, amount of the loss, whether covered by insurance, and corrective procedures implemented.

CYBERRISK INFORMATION

1.	a. Title of Applicant’s director or officer responsible for information security:
b. This position reports to:

2.	Indicate if the Applicant has any of the following systems or plans: (Select all that apply.)
Secondary / backup computer system*	Business continuity plan
Incident response plan for network intrusions and virus incidents	Disaster recovery plan
*The secondary / backup computer system is operational within hours.

3.	Indicate if the Applicant has any of the following software or procedures: (Select all that apply.)
Up-to-date active firewall technology	Up-to-date anti-virus software active on all computers and networks
Patch management procedures	Intrusion detection software
Multi-factor login for privileged access	Valuable / sensitive data backup procedures
Remote access limited to VPN	Procedure to test or audit network security controls

4.	Does the Applicant:
a. have a plan to prevent unauthorized access to its mobile devices (e.g.: laptops, smartphones, tablets) if the device is lost or stolen?	Yes No
b. conduct employee training on security issues and procedures?	Yes No
c. terminate computer access when an employee leaves the company?	Yes No
d. have procedures for creating and updating passwords?	Yes No
e. conduct background checks on prospective employees?	Yes No
f. require its service providers to demonstrate adequate security policies and procedures?	Yes No

10.	Do the Applicant’s contracts with service providers include hold harmless and indemnification agreements?	Yes No

11.	Indicate if the Applicant collects, receives, processes, transmits, or maintains any of the following types of data as part of its business activities: (Select all that apply.)
Credit / Debit Card Data	Medical Information	Bank Accounts and Records
Social Insurance Numbers / Social Security Numbers	Employee / HR Information	Intellectual Property of Others

12.	What is the maximum number of unique individuals for whom the Applicant collects, stores, or processes any amount of personal information?

13.	Is the Applicant currently compliant with Payment Card Industry Data Security Standards (PCI-DSS)?	N/A	Yes No
Indicate the total number of annual credit card transactions:

14.	Does the Applicant encrypt private or sensitive information? (If Yes, select all that apply.)	Yes No
Data at rest	Data in transit	Data on mobile devices (e.g.: laptops, PDAs, USB drives, etc.)

15.	Does the Applicant have a written intellectual property clearance procedure for posting content on the Applicant’s website?	Yes No

16.	Were any trademarks the Applicant acquired from others in the past 3 years screened for infringement?	N/A	Yes No

17.	Does the Applicant have formal policies or procedures for the following issues:
a. Avoid posting offensive or infringing content?	Yes No
b. Edit or remove offensive or infringing content from material distributed or published by or on behalf of the Applicant?	Yes No
c. Respond to allegations that content created, displayed, or published by the Applicant is libelous, infringing, or in violation of a third party’s privacy rights?	Yes No
d. Obtain parental permission for collecting data on children who use the Applicant’s website?	N/A	Yes No

INCIDENT OR LOSS INFORMATION — CYBERRISK

18.	In the past 3 years, has the Applicant:
a. received any claims or complaints concerning privacy, breach of information, network security unauthorized disclosure of information, defamation, or content infringement?	Yes No
b. been subject to any government action, investigation, or subpoena regarding any alleged violation of a privacy law or regulation?	Yes No
c. notified consumers or any other third party of a data breach incident?	Yes No
d. experienced an actual or attempted extortion demand related to its computer systems?	Yes No
If “Yes”, attach details of each claim, complaint, allegation or incident, including date, costs, losses or damages incurred or paid, any corrective procedures implemented, and any amounts paid as loss under any insurance policy.

REQUIRED ATTACHMENTS — CYBERRISK

19.	As part of this Application, submit the following documents:
a. If requested Limit of Liability for Network and Information Security Liability Coverage exceeds $3,000,000, submit most current audited or annual financial statements.
These documents, and the representations and facts they contain, are made a part of this Application, whether such documents are physically delivered to Travelers Insurance Company of Canada by the Applicant or are obtained by Travelers Insurance Company of Canada from any public source, including the Internet.

IDENTITY FRAUD EXPENSE REIMBURSEMENT INFORMATION

1.	Is the Applicant interested in a quote for Identity Fraud Expense Reimbursement Coverage for anyone other than directors or officers?	Yes No

2.	Indicate the total number of proposed insureds as of the policy effective date: (Do not include spouses or family members.)

3.	Describe how the proposed insureds are categorized or grouped and their relationship to the Applicant:
Group	Categorization	Relationship to Applicant
Group One
Group Two

4.	Does the Applicant maintain privacy policies pertaining to customer information?	Yes No

5.	Does the Applicant have loss prevention or loss mitigation protocols for addressing a potential information breach?	Yes No
If “Yes”, attach an explanation.

REQUESTED INSURANCE TERMS — IDENTITY FRAUD EXPENSE REIMBURSEMENT

6.	Coverage	Coverage Requested	Requested Limit	Requested Retention
Identity Fraud Expense Reimbursement Coverage — Group One	$1,000 $10,000 $5,000 $25,000	$0 $250 $100
Identity Fraud Expense Reimbursement Coverage — Group Two (if applicable)	$1,000 $10,000 $5,000 $25,000	$0 $250 $100
Spouse/Domestic Partner Coverage	(same as Group One)	(same as Group One)
Family Coverage (includes Spouse/Domestic Partner)	(same as Group One)	(same as Group One)
Identity Fraud Resolution Services	(same as Group One)	(same as Group One)

LOSS INFORMATION — IDENTITY FRAUD EXPENSE REIMBURSEMENT

7.	Is the Applicant or any person proposed for this insurance aware of any situation that may cause a loss under this policy?	Yes No

8.	Has the Applicant experienced a data theft, data breach, or loss of employee, customer, or member information in the past 3 years?	Yes No
If questions 7. or 8. are answered “Yes”, attach an explanation.

WARRANTY

1.	Is the Applicant, or any person proposed for this insurance aware of any fact, circumstance, situation, event, or act that reasonably could give rise to a claim against them under the Liability Coverage for which the Applicant is applying?	Yes No

2.	Solely as respects any higher limits requested or that may ultimately be issued for the proposed insurance, is the Applicant or any person proposed for this insurance aware of any fact, circumstance, situation, event, or act that reasonably could give rise to a claim against them under the Liability Coverage for which the Applicant is applying?	Yes No
If questions 1. or 2. are answered “Yes”, attach an explanation.

As respects the information required to be disclosed in response to the questions above, the proposed insurance will not afford coverage for any claim arising from any fact, circumstance, situation, event, or act about which any executive officer of the Applicant had knowledge prior to the Continuity Date set out in the Declarations of the Applicant’s policy.

SIGNATURE AND PRIVACY CONSENT

1.	The undersigned Authorized Representative represents that to the best of their knowledge and belief, and after reasonable inquiry, the statements provided in response to this Application and all attached Coverage Section Applications, including Supplemental Applications (collectively, “the Application”), are true and complete, and may be relied upon by Travelers Insurance Company of Canada as the basis for providing insurance. The Applicant will notify Travelers Insurance Company of Canada of any material changes to the information provided. This Application, including any requested or submitted information, will be deemed attached to and form a part of any policy issued.

2.	The undersigned Authorized Representative hereby consents to the collection, use, and disclosure of:

a.	the undersigned’s personal information; or

b.	the personal information of a third party (such as a family member, director, officer, or employee); and the undersigned represents they have obtained that person’s consent to such collection, use, and disclosure in accordance with Travelers Insurance Company of Canada’s Privacy Policy*;

in the ordinary course of business:

(1)	for the purposes of underwriting bonds, policies of insurance, and all other related insurance products offered by Travelers Insurance Company of Canada and all related documentation, bond, or policy management (which includes: handling customer complaints; any activities associated with extensions, renewals, substitutions, and modifications of such bond or policy of insurance; and claims administration); or

(2)	by and to its affiliates, reinsurers, legal advisors, other financial institutions, regulatory bodies, and any third party deemed necessary by Travelers Insurance Company of Canada.

*Travelers Insurance Company of Canada’s Privacy Policy is available online at www.travelerscanada.ca. If you have any questions about our Privacy Policy, contact our Privacy Officer at 1.800.268.8447 or 416.362.7231.

Authorized Representative Signature*: (President, CEO or Chairman) X	Authorized Representative Name and Title	Date (dd/MON/yyyy):

*If you are electronically submitting this document, apply your electronic signature to this form by checking the Electronic Signature and Acceptance box below. By doing so, you agree that your use of a key pad, mouse, or other device to check the Electronic Signature and Acceptance box constitutes your signature, acceptance, and agreement as if actually signed by you in writing and has the same force and effect as a signature affixed by hand.

Electronic Signature and Acceptance – Authorized Representative