Travelers Insurance Company of Canada	Private Company Renewal 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:

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 actual or proposed merger, acquisition, or divestiture?	Yes No
b. Any creation of a new business, subsidiary, or division?	Yes No
c. A private placement of securities or registration for a public offering?	Yes No
d. Any reorganization or arrangement with creditors under federal, provincial, territorial, or state law?	Yes No
e. Any branch, location, facility, office, or subsidiary closings, consolidations, or layoffs?	Yes No
If any part of question 1. is answered “Yes”, provide an explanation, including the timing, the essential terms of the event, the arrangement, the impact on employee base, and the surrounding circumstances.

2.	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

FINANCIAL INFORMATION

3.	Complete the table with the Applicant’s most recent and prior fiscal year end (“FYE”) financial information. Not required if Applicant provides financial statements. Indicate negative figures with “( )”or “-“.
Financial Information	Most Recent FYE ( / ) (mm/yyyy)	Prior FYE ( / ) (mm/yyyy)
Current Assets	$	$
Total Assets	$	$
Current Liabilities	$	$
Long Term Debt	$	$
Retained Earnings (Accumulated Deficit/Fund Deficit)	$	$
Net Equity/Net Assets (Deficit Equity)	$	$
Revenues	$	$
Net Income (Net Loss)	$	$
Cash Flow from Operations	$	$

4.	Is the Applicant currently (or has it been in the past 24 months) in violation of, or in receipt of any amendment to, a debt covenant?	Yes No

5	Is the Applicant currently in arrears in its payments to Canada Revenue Agency or the provincial ministries of revenue (including source deductions, G.S.T., and P.S.T.)?	Yes No

6.	Has the Applicant’s outside auditor: (Check here if not applicable: )
a. issued a “going concern” opinion for the Applicant’s financial statement in the past 12 months?	Yes No
b. been changed in the past year?	Yes No
If any part of questions 4. to 6. is answered “Yes”, provide an explanation.

INSURANCE INFORMATION

7.	Provide details about the Applicant’s expiring and requested insurance coverage. Note: Coverage checkbox must be selected to reveal coverage specific questions.
Coverage Requested	Expiring Limit	Expiring Retention	Requested Limit	Requested Retention
Private Company Directors and Officers Liability	$	$	$	$
Employment Practices Liability	$	$	$	$
Fiduciary Liability	$	$	$	$
Miscellaneous Professional Liability	$	$	$	$
Crime	$	$	$	$
Option: Social Engineering	$	$	$	$
Kidnap and Ransom	$	$	$	$
CyberRisk	$	$	$	$
Identity Fraud Expense Reimbursement	$	$	$	$

PRIVATE COMPANY DIRECTORS AND OFFICERS LIABILITY INFORMATION

1.	Have there been any changes in the Applicant’s board of directors or senior management within the past 12 months for reasons other than retirement or death?	Yes No

2.	Are there currently outstanding loans to any director or officer?	Yes No
If question 1. or 2. is answered “Yes”, provide an explanation.

REQUIRED ATTACHMENTS — PRIVATE COMPANY DIRECTORS AND OFFICERS LIABILITY

3.	As part of this Application, submit the following documents:
a. Most recent annual financial statement if (i) limit requested is greater than $3,000,000 or (ii) assets are greater than $100 million or (iii) net income was negative in any of the past 2 fiscal years.
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:

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

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

REQUIRED ATTACHMENTS — EMPLOYMENT PRACTICES LIABILITY

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

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.	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

3.	In the next 12 months will any of the following occur, or have any of the following occurred during the past 12 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

4.	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 3. or 4. is answered “Yes”, provide an explanation.

REQUIRED ATTACHMENTS — FIDUCIARY LIABILITY

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

3.	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

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

5.	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

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

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

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

SOCIAL ENGINEERING INFORMATION

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

10.	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

11.	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

12.	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

13.	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

14.	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

15.	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

16.	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.

17.	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:

18.	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

REQUIRED ATTACHMENTS — CRIME

19.	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 greater than $5,000,000.
b. Most recent annual financial statement if limit requested is greater than $5,000,000.

CYBERRISK INFORMATION

1.	a. Has there been a change to the Applicant’s director or officer responsible for information security:	Yes No

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.	Have there been any material changes to security policies or procedures provided to employees?
If “Yes”, describe the changes:

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

6.	Is the Applicant currently compliant with Payment Card Industry Data Security Standards (PCI-DSS)?	N/A	Yes No

7.	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.)

8.	Has there been any material change to policies or procedures relating to written intellectual property clearance procedure for posting content on the Applicant’s website or other electronic material?	Yes No
If “Yes”, describe the changes:

REQUIRED ATTACHMENTS — CYBERRISK

9.	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

WARRANTY – COMPLETE ONLY IF REQUESTING HIGHER LIMITS OF INSURANCE THAN EXPIRING LIMITS

1.	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 “Yes”, provide 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 or CEO) 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