1

Proposer Company Name1.

2. (a) Status of the Proposer:

This has not changed in the last 3 years? If ‘False’, please provide details in the Additional Information Section

FalseTrue

Private Limited by Shares

Public Limited Company

Limited Liability Partnership

Management Liability InsuranceProposal FormThe term “Proposer” on this form includes the Proposer Company/ Organisation/ Association and all of its current and former subsidiaries.

1General Information

3.

4.

CanadaUK

(ii) Date of Incorporation:

(b) (i) Country of Incorporation (Domicile if n/a):

(iii) Company Registration Number:

Other

Address

Website

2

Management Liability InsuranceProposal Form

1General Information Continued

2Financial Information

7. Subsidiary Information:

Name of Subsidiary Country of Registration Ownership %

8. (a) The Proposer is not listed and its shares aren’t issued or publicly traded on any stock exchange. If False, please complete Sections 1 to 5, 7(PLC Supplementary Page) and 8-10.

FalseTrue

14. (a) The Proposer has not sold any subsidiary or acquired any company or concerns since its last financial year end that have increased total gross assets by 30% or more.

FalseTrue

(b) The Proposer plans to remain this way for the next 18 months FalseTrue

(b) The Proposer has no mergers, acquisitions or disposals planned. FalseTrue

9. The Proposer does not have any shareholders who hold a stake of 15% or more. FalseTrue

10. The Proposer has not raised funds from any external parties (including but not limited to the public offering of securities) within the last 2 years and they have no plans to do so over the next 18 months.

FalseTrue

11. No loan covenants have been breached in the last 12 months and no breach is anticipated. FalseTrue

12. The Proposer has been in operation for at least 12 months. FalseTrue

13. The Proposer’s latest financial statements:

• Areauditedorifauditingisnotrequired,arepreparedbyaqualifiedaccountant FalseTrue

• Arelessthan18monthsold FalseTrue

• AreNOTqualifiedanddonotcontainanyconcerns FalseTrue

• Showapre-taxprofit.Apre-taxprofitisalsoexpectedinthecurrentfinancialyear FalseTrue

• Showpositivenetassets FalseTrue

If any questions are answered False, please provide details in the Additional Information Section.

5. Proposer and subsidiaries’ (including former) activities since establishment:

6. Ultimate Parent Company and registration number (if applicable)

3

Management Liability InsuranceProposal Form

3Activities And Turnover

15. No past, present or future planned business of the Proposer or its subsidiaries are involved in the following areas:

• FinancialInstitutions(includingbutnotlimitedtoCreditUnions,BuildingSocieties,FinanceProviders,Fund Managers,InvestmentBanks,MortgageBank/Savings&Loans,National/InternationalBank,StateBank, Stock Exchange, Pension Schemes (Final Salary), Venture Capitalists/ Private Equity Firms.

FalseTrue

• InsuranceCompanies,LloydsSyndicates,MGAs. FalseTrue

• News,mediaandbroadcastingorganisations FalseTrue

• SocialNetworking FalseTrue

• CosmeticSurgeryFacilities FalseTrue

16. Are procedures in place, which are reviewed at least annually, ensuring compliance with all relevant health&safetyregulation?

FalseTrue

17. GeographicalturnoversplitforProposer.

* Please provide a detailed geographical split for any Other turnover

4Employment Practices Liability (Optional Coverage) For UK incorporated (domiciled if not incorporated) proposer’s only

19. Employee* territory split

* Includes all part-time, seasonal workers and volunteers

** Please elaborate regarding all employees not domiciled in or working in the UK

UK

EU**

USA/Canada**

Other**

TOTAL

Last Financial Year Current Financial Year Next Financial YearTerritory

18. The Proposer has no subsidiaries, assets, directors or shareholders in the USA FalseTrue

If any questions are answered False, please provide details in the Additional Information Section

UK £

EU £ equivalent

Canada £ equivalent

USA £ equivalent

Other*, £ equivalent

TOTAL £

DD MM YY DD MM YY DD MM YY

Last Complete Financial Year

Projected Current Financial Year

Projected Next Financial Year

Territory

4

Management Liability InsuranceProposal Form

4Employment Practices Liability (Optional Coverage) Continued

5Claims History

20. The Proposer’s total annual payroll divided by the total number of employees is less than £50,000 FalseTrue

24. After a full investigation:

21. None of the Proposer’s employees are permanently based in EC, WC or W1. FalseTrue

22. The Proposer’s employees are not engaged in:

23. The Proposer:

• TheEntertainmentIndustry(includingbutnotlimitedtonightclubs,pubs,bars,restaurants, private members clubs)

FalseTrue

• Ensuresthatallexistingandfutureemployeeshaveasignedcontractofemployment FalseTrue

• Doctorsurgeries,dentalpractices,cosmeticsurgeryfacilities FalseTrue

• Haswell-documentedemploymentandgrievancepoliciesinplaceforreportingcomplaints that are properly communicated to all employees

FalseTrue

• Churchorganisations FalseTrue

• Hasnotdismissedormadeanyemployeesredundantinthelast6months FalseTrue

• News,media,broadcasting FalseTrue

• Isnotcurrentlyundergoingorcontemplatinganyredundanciesorterminationswithinthe next 12 months.

FalseTrue

• Thelegalsector FalseTrue

• Priortoanydisciplinaryaction,suspension,redundancyordismissal,consultswithahumanresources consultant, qualified employment consultant or law firm specialising in employment law.

FalseTrue

If any questions are answered False, please provide details in the Additional Information Section

• TheProposer,itsDirectors,Officers,TrusteesandCommitteeMembersarenotawareofanyclaimsthat have previously been made, or any fact, circumstance or allegation which may give rise to a claim being made in the future.

FalseTrue

• TheProposer,itsDirectors,Officers,TrusteesandCommitteeMembershavenotbeenfoundguiltyofany criminal, dishonest or fraudulent activity, have not been disqualified from acting as a Director, Trustee or Committee Member and have not been the subject of an investigation by any government authority, official body or institution, accountants, liquidators or receivers.

• TheProposer,itsDirectors,Officers,TrusteesandCommitteeMembershavenotbeenrefusedthistype of insurance or had similar insurance cancelled or special terms imposed

FalseTrue

If any questions are answered False, please provide details in the Additional Information Section

5

Management Liability InsuranceProposal Form

Additional Information (including any information you feel may be material to the risk. If you are unsure as to whether any information is material, please disclose it)

6

Management Liability InsuranceProposal Form

Fidelity Guarantee and Pension Trustee Liability6

If False to any of the above, please provide full details:

4. Bankstatements,receipts,counterfoilsandsupportingdocumentationareindependentlycheckedatleasmonthly against the cash book entries and bank statements of the employee making the entries or paying into the bank

FalseTrue

NoYes1. IscoverrequiredforFidelityGuarantee?

Please state the Limit required.

2. The Proposer has no authority to handle client monies FalseTrue

3. No person is allowed to sign cheques or make electronic transfers without a counter-signature FalseTrue

5. The Proposer does not store money, securities or precious metals with a value in excess of £10,000 FalseTrue

6. All cheques and cash paid into the bank daily? FalseTrue

Fidelity Guarantee

Pension Trustee Liability

6. In the past 24 months have there been, or, in the next 12 months are there anticipated:

(a) any amendments in the plan scheme, benefits or participants’ share of costs or FalseTrue

(b) any plan termination or any merger with another plan? FalseTrue

NoYes1. Is cover required for Pension Trustee Liability?

Please state the Limit required.

4. There are no defined benefit plans FalseTrue

5. All defined benefit plans adequately funded FalseTrue

If False, please complete Plan Details below for each applicable plan.

If True, please complete Supplemental Plan Details below for each applicable plan including full details on such plan amendments, terminations or mergers.

2. Number of pension plans

3. Total assets of all pension plans UK £

7

Management Liability InsuranceProposal Form

Fidelity Guarantee and Pension Trustee Liability Continued

7. Are any of the pension plans subject to the Employee Retirement Income Security Act of 1974 (ERISA)? FalseTrue

The plan does not invest in employer securities other than employer securities that are incidentally held in a fund FalseTrue

Is the employer company and or any of its subsidiaries a Corporate Trustee Company? FalseTrue

Name of Plan

8. If True does any ERISA plan contains employer securities?

If True, please complete Plan Details for each applicable plan.

N/AFalseTrue

6

Pension Trustee Liability Continued

Supplemental Plan Details

Current market value of plan assets

Number of active members

Number of deferred members

Number of retired members

UK £

If False, please provide details on investment terms including restrictions on sale of such securities.

If False to (a), (b), or (c), then please provide full details.

With regard to the services providers (Custodian, Administrator, Investment Manager, Legal Advisor, Actuary) for the plan:

(a) Are all non-affiliated with the employer or trustees? FalseTrue

(b) Are all appointed or approved by the trustees? FalseTrue

Are all plan assets held in custodianship independently from the employer company and investment manager? FalseTrue

(c) Does the Investment Manager possess full investment discretion? FalseTrue

8

Management Liability InsuranceProposal Form

Fidelity Guarantee and Pension Trustee Liability Continued

HavetherebeenanyknownviolationsofERISA? FalseTrue

If True, please provide details by attachment.

6

ERISA Plan Details (if applicable)

Additional Information (including any information you feel may be material to the risk. If you are unsure as to whether any information is material, please disclose it)

9

Management Liability InsuranceProposal Form

Public Limited Company Supplementary Page

1. Please enclose:

• TheProposer’slatestsignedReportandAccounts

• AnyProspectusissuedinthelast12months

• Anyinterimstatements

2. On which stock exchange are the Proposer’s shares traded?

5. (a) Who are the Proposer’s auditors?

(b) For how long have they been appointed?

3. What is the Proposer’s current market capitalisation?

4. TheProposeroperatesincompliancewiththeUKCorporateGovernanceCode (or foreign equivalent if applicable)

FalseTrue

6. The Proposer does not plan to make any changes to its revenue recognition policy that are as yet unapproved by the Proposer’s auditor

FalseTrue

8. The Proposer does not anticipate posting any one-time write-down or impairment charges over the proposed policy period

FalseTrue

7. The Proposer does not use any special purpose vehicles or any off balance sheet entities FalseTrue

9. No shareholders requested a revision of the Proposer’s existing remuneration policy FalseTrue

If any questions are answered False, please provide details in the Additional Information Section

Additional Information

7

(including any information you feel may be material to the risk. If you are unsure as to whether any information is material, please disclose it)

10

Management Liability InsuranceProposal Form

10Declaration

Type of Coverage (please tick):

Corporate Employment Practices Liability

Corporate LiabilityD&O

Limits (please tick): £3,000,000 £5,000,000

Other:

£1,000,000 £2,000,000 £500,000 £250,000

Coverage Options8

Current Insurance Details

Insurer:

Type of Coverage:

Limit: Renewal Date: if n/a Proposed Inception Date

9

Signature of Partner/Director/Principal:

For and/on behalf of the Proposer:

Name in capital letters (Printed):

Date:

I/We declare that the above answers, statements, particulars and additional information are true to the very best of our knowledge and belief and that after full enquiry, I/We have disclosed all information and material facts that may affect the Insurer’s assessment of the risk. I/We understand that all answers, statements, particulars and additional information supplied with this proposal form will become part of and form the basis of the contract effected therein.