Travelers Insurance Company of Canada	Small Non-Profit Organization Directors and Officers Liability and Employment Practices Liability Application
This Application will only be accepted for Non Profit Organizations that meet all 3 requirements: (i) 50 or fewer employees; (ii) $5 million or less in assets; and (iii) $5 million or less in revenues.

The information requested in this application is for claims-made coverage sections. If issued, the claims made coverage sections 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.	Description of Applicant’s Operations:

2.	Year Applicant’s business was established:	SIC Code (if known):

3.	Does the Applicant:
a. Have tax-exempt status under the Income Tax Act (Canada)?	Yes No
b. Consult with legal counsel or human resources personnel prior to every employee termination?	Yes No
c. Have formal written policies and procedures related to discrimination, sexual and other workplace harassment, disabled employees and accommodations?	Yes No
If any part of question 3 is answered “No”, attach an explanation.

4.	Does the Applicant:
a. Anticipate in the next 12 months, or has the Applicant had in the past 24 months, any changes in nature of operations, sources of revenue or operational status, or layoffs?	Yes No
b. Have any subsidiaries or control any other entity for which coverage is requested?	Yes No
c. Provide professional services to its members or the public on a fee-for-service basis?	Yes No
d. Conduct professional ethics, peer review, accreditation, member certification or licensing activities?	Yes No
e. Sponsor or provide any form of insurance, financial services or loans to its members or the public?	Yes No
f. Engage in publishing, other than a newsletter or brochure?	Yes No
If any part of question 4 is answered “Yes”, attach an explanation.

5.	Complete the table with the location and employee information:
Country	Number of Locations	Full-Time* Employees	Part-Time** Employees	Employee Turnover	Volunteers
Canada
United States of America
*Including leased employees **Including seasonal and temporary employees

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

7.	Is the Applicant currently (or has it been in the past 24 months) in violation of, or receipt of any amendment to, a debt covenant?	Yes No
8.	Is the Applicant currently in arrears in its payments to the Canada Revenue Agency or the provincial ministries of revenue (including source deductions, G.S.T., and P.S.T.)?	Yes No

WARRANTY AND loss information

9.	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
10.	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 9. or 10. 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.

11.	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?	Yes No
If “Yes”, complete the table:
Claim 1	Date: (dd/MON/yyyy)
Nature of Claim
Amount Paid for Defence	$	Amount Sought or Paid for Damages	$	Covered by Insurance?	Yes No
Corrective Procedures Implemented
Current Status

REQUIRED ATTACHMENTS

12.	As part of this Application, submit the following document: Most recent annual financial statement if limit requested is greater than $3,000,000 or net income was negative in any of the past 2 fiscal years.

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 Executive Director) 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