ACORD 807 (2014/12) - Directors and Officers Liability Application
ACORD 807 (2014/12) - Directors and Officers Liability Application
ACORD 807, Directors & Officers Liability Section, is used to apply for Directors and Officers liability coverage.
The form was designed to be used in conjunction with ACORD 825, Professional / Specialty Insurance Application. This form must be attached to
ACORD 825 for a completed application submission.
Form Page 1
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
IDENTIFICATION SECTION
Date
Enter date: The date on which the form is completed. (MM/DD/YYYY)
IDENTIFICATION SECTION
Agency
Enter text: The full name of the producer / agency.
IDENTIFICATION SECTION
Policy Number
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being
referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for
self-insurance, the self-insured license or contract number.
IDENTIFICATION SECTION
Requested Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the policy
commence. (MM/DD/YYYY)
IDENTIFICATION SECTION
Carrier
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy. Use
the actual name of the company within the group to which the policy has been issued. This is
not the insurer's group name or trade name.
IDENTIFICATION SECTION
NAIC Code
Enter code: The identification code assigned to the insurer by the NAIC.
IDENTIFICATION SECTION
First Named Insured
Enter text: The named insured(s) as it / they will appear on the policy declarations page. As
used here, this is the first named insured.
IDENTIFICATION SECTION
Expiration Date
Enter date: The date on which the terms and conditions of the policy will expire. (MM/DD/YYYY)
COVERAGES
Primary
Check the box (if applicable): Indicates the directors and officers coverage is primary.
COVERAGES
Excess
Check the box (if applicable): Indicates the directors and officers coverage is excess.
COVERAGES
Requested Limits Per Claim
Enter limit: The requested per claim limit amount for directors and officers coverage.
COVERAGES
Requested Limits Aggregate
Enter limit: The requested aggregate limit amount for directors and officers coverage.
COVERAGES
Current Limits Per Claim
Enter limit: The current per claim limit amount for directors and officers coverage.
COVERAGES
Current Limits Aggregate
Enter limit: The current aggregate limit amount for directors and officers coverage.
COVERAGES
Requested Retention
Enter amount: The requested retention amount for directors and officers coverage.
ACORD 807 (2014/12) rev. 05-29-2014
Page 1 of 18
COVERAGES
Current Retention
Enter amount: The current retention amount for directors and officers coverage.
COVERAGES
Primary
Check the box (if applicable): Indicates the company reimbursement coverage is primary.
COVERAGES
Excess
Check the box (if applicable): Indicates the company reimbursement coverage is excess.
COVERAGES
Requested Limits Per Claim
Enter limit: The requested per claim limit amount for company reimbursement coverage.
COVERAGES
Requested Limits Aggregate
Enter limit: The requested aggregate limit amount for company reimbursement coverage.
COVERAGES
Current Limits Per Claim
Enter limit: The current per claim limit amount for company reimbursement coverage.
COVERAGES
Current Limits Aggregate
Enter limit: The current aggregate limit amount for company reimbursement coverage.
COVERAGES
Requested Retention
Enter amount: The requested retention amount for company reimbursement coverage.
COVERAGES
Current Retention
Enter amount: The current retention amount for company reimbursement coverage.
COVERAGES
Primary
Check the box (if applicable): Indicates the company / entity liability coverage is primary.
COVERAGES
Excess
Check the box (if applicable): Indicates the company / entity liability coverage is excess.
COVERAGES
Requested Limits Per Claim
Enter limit: The requested per claim limit amount for company / entity liability coverage.
COVERAGES
Requested Limits Aggregate
Enter limit: The requested aggregate limit amount for company / entity liability coverage.
COVERAGES
Current Limits Per Claim
Enter limit: The current per claim limit amount for company / entity liability coverage.
COVERAGES
Current Limits Aggregate
Enter limit: The current aggregate limit amount for company / entity liability coverage.
COVERAGES
Requested Retention
Enter amount: The requested retention amount for company / entity liability coverage.
COVERAGES
Current Retention
Enter amount: The current retention amount for company / entity liability coverage.
COVERAGES
Other Coverages
Enter text: The description of the coverage.
COVERAGES
Primary
Check the box (if applicable): Indicates the coverage is primary.
COVERAGES
Excess
Check the box (if applicable): Indicates the coverage is excess.
COVERAGES
Requested Limits Per Claim
Enter limit: The requested per claim limit amount for the coverage.
COVERAGES
Requested Limits Aggregate
Enter limit: The requested aggregate limit amount for the coverage.
COVERAGES
Current Limits Per Claim
Enter limit: The current per claim limit amount for the coverage.
COVERAGES
Current Limits Aggregate
Enter limit: The current aggregate limit amount for the coverage.
COVERAGES
Requested Retention
Enter amount: The requested retention amount for the coverage.
COVERAGES
Current Retention
Enter amount: The current retention amount for the coverage.
COVERAGES
Other Coverages
Enter text: The description of the coverage.
ACORD 807 (2014/12) rev. 05-29-2014
Page 2 of 18
COVERAGES
Primary
Check the box (if applicable): Indicates the coverage is primary.
COVERAGES
Excess
Check the box (if applicable): Indicates the coverage is excess.
COVERAGES
Requested Limits Per Claim
Enter limit: The requested per claim limit amount for the coverage.
COVERAGES
Requested Limits Aggregate
Enter limit: The requested aggregate limit amount for the coverage.
COVERAGES
Current Limits Per Claim
Enter limit: The current per claim limit amount for the coverage.
COVERAGES
Current Limits Aggregate
Enter limit: The current aggregate limit amount for the coverage.
COVERAGES
Requested Retention
Enter amount: The requested retention amount for the coverage.
COVERAGES
Current Retention
Enter amount: The current retention amount for the coverage.
COVERAGES
Separate Defense Costs
Limit (Y / N)
Enter Y for a Yes response. Input N for No response. Indicates if there is a separate defense
costs limit for the coverage.
COVERAGES
Separate Defense Costs
Limit
Enter limit: The limit amount for separate defense costs.
COVERAGES
Defense Limit - Inside
Check the box (if applicable): Indicates the defense limit is inside.
COVERAGES
Defense Limit - Outside
Check the box (if applicable): Indicates the defense limit is outside.
COVERAGES
Pending & Prior Litigation
Date
Enter date: The pending and prior litigation date.
SHARED LIMITS
Shared Limits
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are there shared limits?.
SHARED LIMITS
Additional Coverages
Attached
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Additional coverages attached?.
SHARED LIMITS
EPLI
Check the box (if applicable): Indicates the Employment Practices Liability Insurance (EPLI)
section is attached to this application.
SHARED LIMITS
Prof Liability
Check the box (if applicable): Indicates the Professional Liability section is attached to the
application.
SHARED LIMITS
Crime
Check the box (if applicable): Indicates the Crime section is attached to this application.
SHARED LIMITS
Fiduciary
Check the box (if applicable): Indicates the Fiduciary section is attached to the application.
SHARED LIMITS
Other
Check the box (if applicable): Indicates that a section other than those listed is attached to this
application.
SHARED LIMITS
Other Description
Enter text: The type of section being attached to this application.
SHARED LIMITS
Other
Check the box (if applicable): Indicates that a section other than those listed is attached to this
application.
ACORD 807 (2014/12) rev. 05-29-2014
Page 3 of 18
SHARED LIMITS
Other Description
Enter text: The type of section being attached to this application.
ENDORSEMENTS
World Wide Coverage
Check the box (if applicable): Indicates the world wide coverage endorsement applies.
ENDORSEMENTS
Form Number
Enter identifier: The number used by the insurer for this form.
ENDORSEMENTS
Title
Enter text: The name of the form.
ENDORSEMENTS
Edition Date
Enter date: The edition date of the form.
ENDORSEMENTS
Duly Constituted Committee
Charge
Check the box (if applicable): Indicates the duly constituted committee charge endorsement
applies.
ENDORSEMENTS
Form Number
Enter identifier: The number used by the insurer for this form.
ENDORSEMENTS
Title
Enter text: The name of the form.
ENDORSEMENTS
Edition Date
Enter date: The edition date of the form.
ENDORSEMENTS
ODL - Non Profit
Check the box (if applicable): Indicates the outside directorship liability (ODL) non profit
endorsement applies.
ENDORSEMENTS
Form Number
Enter identifier: The number used by the insurer for this form.
ENDORSEMENTS
Title
Enter text: The name of the form.
ENDORSEMENTS
Edition Date
Enter date: The edition date of the form.
ENDORSEMENTS
ODL - For Profit
Check the box (if applicable): Indicates the outside directorship liability (ODL) for profit
endorsement applies.
ENDORSEMENTS
Form Number
Enter identifier: The number used by the insurer for this form.
ENDORSEMENTS
Title
Enter text: The name of the form.
ENDORSEMENTS
Edition Date
Enter date: The edition date of the form.
ENDORSEMENTS
Professional Services
Coverage
Check the box (if applicable): Indicates the professional services coverage endorsement
applies.
ENDORSEMENTS
Form Number
Enter identifier: The number used by the insurer for this form.
ENDORSEMENTS
Title
Enter text: The name of the form.
ENDORSEMENTS
Edition Date
Enter date: The edition date of the form.
ENDORSEMENTS
Check the box (if applicable): Indicates the endorsement form described applies to the policy.
ENDORSEMENTS
Enter text: The description of the form.
ENDORSEMENTS
Enter identifier: The number used by the insurer for this form.
ACORD 807 (2014/12) rev. 05-29-2014
Page 4 of 18
ENDORSEMENTS
Enter text: The name of the form.
ENDORSEMENTS
Enter date: The edition date of the form.
ENDORSEMENTS
Check the box (if applicable): Indicates the endorsement form described applies to the policy.
ENDORSEMENTS
Enter text: The description of the form.
ENDORSEMENTS
Enter identifier: The number used by the insurer for this form.
ENDORSEMENTS
Enter text: The name of the form.
ENDORSEMENTS
Enter date: The edition date of the form.
ENDORSEMENTS
Check the box (if applicable): Indicates the endorsement form described applies to the policy.
ENDORSEMENTS
Enter text: The description of the form.
ENDORSEMENTS
Enter identifier: The number used by the insurer for this form.
ENDORSEMENTS
Enter text: The name of the form.
ENDORSEMENTS
Enter date: The edition date of the form.
ENDORSEMENTS
Check the box (if applicable): Indicates the endorsement form described applies to the policy.
ENDORSEMENTS
Enter text: The description of the form.
ENDORSEMENTS
Enter identifier: The number used by the insurer for this form.
ENDORSEMENTS
Enter text: The name of the form.
ENDORSEMENTS
Enter date: The edition date of the form.
ENDORSEMENTS
Check the box (if applicable): Indicates the endorsement form described applies to the policy.
ENDORSEMENTS
Enter text: The description of the form.
ENDORSEMENTS
Enter identifier: The number used by the insurer for this form.
ENDORSEMENTS
Enter text: The name of the form.
ENDORSEMENTS
Enter date: The edition date of the form.
ENDORSEMENTS
Check the box (if applicable): Indicates the endorsement form described applies to the policy.
ENDORSEMENTS
Enter text: The description of the form.
ENDORSEMENTS
Enter identifier: The number used by the insurer for this form.
ENDORSEMENTS
Enter text: The name of the form.
ENDORSEMENTS
Enter date: The edition date of the form.
ACORD 807 (2014/12) rev. 05-29-2014
Page 5 of 18
FINANCIAL STATEMENT
INFORMATION
Date of Financial
Information
Enter date: The date the financial information was prepared. (MM/DD/YYYY)
FINANCIAL STATEMENT
INFORMATION
Period of Financial
Information From:
Enter date: The starting date of the financial information. (MM/DD/YYYY)
FINANCIAL STATEMENT
INFORMATION
Period of Financial
Information To:
Enter date: The end date of the financial information. (MM/DD/YYYY)
FINANCIAL STATEMENT
INFORMATION
Outside Auditor
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is there is an outside auditor?.
FINANCIAL STATEMENT
INFORMATION
Any changes to the outside
financial auditor in the last
three (3) years?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Any changes to the outside financial auditor in the last specified number of years?.
FINANCIAL STATEMENT
INFORMATION
Has any auditor issued a
going concern opinion for
the applicant's or any of its
subsidiaries financial
statements?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Has any auditor issued a going concern opinion for the applicant's or any of its subsidiaries
financial statements?.
FINANCIAL STATEMENT
INFORMATION
Current Year:
Enter year: The year of the current financial information.
FINANCIAL STATEMENT
INFORMATION
Current Year: Total Assets
Enter amount: The total assets of the organization for the current year.
FINANCIAL STATEMENT
INFORMATION
Current Year: Current
Assets
Enter amount: The amount of assets that are cash or are convertible into cash at short notice for
the current year.
FINANCIAL STATEMENT
INFORMATION
Current Year: Inventory
Enter amount: The inventory amount for the current year.
FINANCIAL STATEMENT
INFORMATION
Current Year: Cash
Enter amount: The cash amount for the current year.
FINANCIAL STATEMENT
INFORMATION
Current Year: Current
Liabilities
Enter amount: The amount of debt that becomes due within one year for the current year.
FINANCIAL STATEMENT
INFORMATION
Current Year: Total
Liabilities
Enter amount: The total liabilities of the organization for the current year.
FINANCIAL STATEMENT
INFORMATION
Current Year: Total Revenue
Enter amount: The total revenue for the organization for the current year.
FINANCIAL STATEMENT
INFORMATION
Current Year: Net Income /
Loss
Enter amount: The excess amount of revenue over expenses for the current year. This may be
a net loss amount.
ACORD 807 (2014/12) rev. 05-29-2014
Page 6 of 18
FINANCIAL STATEMENT
INFORMATION
Prior Year:
Enter year: The year of the prior financial information.
FINANCIAL STATEMENT
INFORMATION
Prior Year: Total Assets
Enter amount: The total assets of the organization for the prior year.
FINANCIAL STATEMENT
INFORMATION
Prior Year: Current Assets
Enter amount: The amount of assets that are cash or are convertible into cash at short notice for
the prior year.
FINANCIAL STATEMENT
INFORMATION
Prior Year: Inventory
Enter amount: The inventory amount for the prior year.
FINANCIAL STATEMENT
INFORMATION
Prior Year: Cash
Enter amount: The cash amount for the prior year.
FINANCIAL STATEMENT
INFORMATION
Prior Year: Current
Liabilities
Enter amount: The amount of debt that becomes due within one year for the prior year.
FINANCIAL STATEMENT
INFORMATION
Prior Year: Total Liabilities
Enter amount: The total liabilities of the organization for the prior year.
FINANCIAL STATEMENT
INFORMATION
Prior Year: Total Revenue
Enter amount: The total revenue for the organization for the prior year.
FINANCIAL STATEMENT
INFORMATION
Prior Year: Net Income /
Loss
Enter amount: The excess amount of revenue over expenses for the prior year. This may be a
net loss amount.
NOT FOR PROFIT
Current Year Fund Balance
(Net Assets)
Enter amount: The fund balance (net assets) amount for the current year.
NOT FOR PROFIT
Prior Year Fund Balance
(Net Assets)
Enter amount: The fund balance (net assets) amount for the prior year.
NOT FOR PROFIT
Organization Tax Exempt (Y
/ N)
Enter Y for a Yes response. Input N for No response. Indicates if the organization is exempt
from certain taxes to be paid to the federal government or foreign equivalent.
Form Page 2
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
PRIVATE
Parent Company /
Organization
Enter text: The name of the parent organization.
PRIVATE
Number Of Owners
Enter number: The number of owners.
ACORD 807 (2014/12) rev. 05-29-2014
Page 7 of 18
PRIVATE
Number Of Voting Shares
Outstanding
Enter number: The number of shares outstanding in the voting shares class.
PRIVATE
Total Number Of Voting
Shares
Enter number: The total number of voting shares, including shares not released to the
marketplace.
PRIVATE
Voting Shares Owned By
Directors
Enter number: The total number of voting shares owned by members of the board of directors
PRIVATE
Voting Shares Owned By
Officers
Enter number: Total number of voting shares owned by officers who are not directors.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Name
Enter text: The full name of the director or officer of the organization.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Affiliation With Other
Organizations
Enter text: The name of the organization(s) to which the individual has an affiliation. If no
affiliation exists, indicate none or not applicable.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Name
Enter text: The full name of the director or officer of the organization.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Affiliation With Other
Organizations
Enter text: The name of the organization(s) to which the individual has an affiliation. If no
affiliation exists, indicate none or not applicable.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Name
Enter text: The full name of the director or officer of the organization.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Affiliation With Other
Organizations
Enter text: The name of the organization(s) to which the individual has an affiliation. If no
affiliation exists, indicate none or not applicable.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Name
Enter text: The full name of the director or officer of the organization.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Affiliation With Other
Organizations
Enter text: The name of the organization(s) to which the individual has an affiliation. If no
affiliation exists, indicate none or not applicable.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Name
Enter text: The full name of the director or officer of the organization.
ACORD 807 (2014/12) rev. 05-29-2014
Page 8 of 18
OWNERSHIP /
ORGANIZATION
STRUCTURE
Affiliation With Other
Organizations
Enter text: The name of the organization(s) to which the individual has an affiliation. If no
affiliation exists, indicate none or not applicable.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Name
Enter text: The full name of the director or officer of the organization.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Affiliation With Other
Organizations
Enter text: The name of the organization(s) to which the individual has an affiliation. If no
affiliation exists, indicate none or not applicable.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Name
Enter text: The full name of the director or officer of the organization.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Affiliation With Other
Organizations
Enter text: The name of the organization(s) to which the individual has an affiliation. If no
affiliation exists, indicate none or not applicable.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Name
Enter text: The full name of the director or officer of the organization.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Affiliation With Other
Organizations
Enter text: The name of the organization(s) to which the individual has an affiliation. If no
affiliation exists, indicate none or not applicable.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Name
Enter text: The full name of the director or officer of the organization.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Affiliation With Other
Organizations
Enter text: The name of the organization(s) to which the individual has an affiliation. If no
affiliation exists, indicate none or not applicable.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Name
Enter text: The full name of the director or officer of the organization.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Affiliation With Other
Organizations
Enter text: The name of the organization(s) to which the individual has an affiliation. If no
affiliation exists, indicate none or not applicable.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Name
Enter text: The additional interest's full name. As used here, this is an additional proposed
insured.
ACORD 807 (2014/12) rev. 05-29-2014
Page 9 of 18
OWNERSHIP /
ORGANIZATION
STRUCTURE
Title
Enter text: The title this person has in the current employment position.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Responsibility
Enter text: The description of the duties in the organization of the individual.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Affiliation With Other
Organizations
Enter text: The name of the organization(s) to which the individual has an affiliation. If no
affiliation exists, indicate none or not applicable.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Name
Enter text: The additional interest's full name. As used here, this is an additional proposed
insured.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Title
Enter text: The title this person has in the current employment position.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Responsibility
Enter text: The description of the duties in the organization of the individual.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Affiliation With Other
Organizations
Enter text: The name of the organization(s) to which the individual has an affiliation. If no
affiliation exists, indicate none or not applicable.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Name
Enter text: The additional interest's full name. As used here, this is an additional proposed
insured.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Title
Enter text: The title this person has in the current employment position.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Responsibility
Enter text: The description of the duties in the organization of the individual.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Affiliation With Other
Organizations
Enter text: The name of the organization(s) to which the individual has an affiliation. If no
affiliation exists, indicate none or not applicable.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Name
Enter text: The name of the subsidiary of the company. This may also include owned
foundations or charitable trusts.
ACORD 807 (2014/12) rev. 05-29-2014
Page 10 of 18
OWNERSHIP /
ORGANIZATION
STRUCTURE
Nature Of Business
Enter text: The description of the nature / type of business.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Date Acquired / Created
Enter date: The date the subsidiary, foundation or charitable trust was acquired / created.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Percent Ownership By
Parent
Enter percentage: The percent of ownership by the parent company.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Name
Enter text: The name of the subsidiary of the company. This may also include owned
foundations or charitable trusts.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Nature Of Business
Enter text: The description of the nature / type of business.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Date Acquired / Created
Enter date: The date the subsidiary, foundation or charitable trust was acquired / created.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Percent Ownership By
Parent
Enter percentage: The percent of ownership by the parent company.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Name
Enter text: The name of the subsidiary of the company. This may also include owned
foundations or charitable trusts.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Nature Of Business
Enter text: The description of the nature / type of business.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Date Acquired / Created
Enter date: The date the subsidiary, foundation or charitable trust was acquired / created.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Percent Ownership By
Parent
Enter percentage: The percent of ownership by the parent company.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Name
Enter text: The name of the subsidiary of the company. This may also include owned
foundations or charitable trusts.
ACORD 807 (2014/12) rev. 05-29-2014
Page 11 of 18
OWNERSHIP /
ORGANIZATION
STRUCTURE
Nature Of Business
Enter text: The description of the nature / type of business.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Date Acquired / Created
Enter date: The date the subsidiary, foundation or charitable trust was acquired / created.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Percent Ownership By
Parent
Enter percentage: The percent of ownership by the parent company.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Name
Enter text: The name of the subsidiary of the company. This may also include owned
foundations or charitable trusts.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Nature Of Business
Enter text: The description of the nature / type of business.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Date Acquired / Created
Enter date: The date the subsidiary, foundation or charitable trust was acquired / created.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Percent Ownership By
Parent
Enter percentage: The percent of ownership by the parent company.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Name
Enter text: The name of the subsidiary of the company. This may also include owned
foundations or charitable trusts.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Nature Of Business
Enter text: The description of the nature / type of business.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Date Acquired / Created
Enter date: The date the subsidiary, foundation or charitable trust was acquired / created.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Percent Ownership By
Parent
Enter percentage: The percent of ownership by the parent company.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Name
Enter text: The full name of the shareholder.
ACORD 807 (2014/12) rev. 05-29-2014
Page 12 of 18
OWNERSHIP /
ORGANIZATION
STRUCTURE
Member of Board
Enter Y for a Yes response. Input N for No response. Indicates if the shareholder is a
member of the board of directors.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Percent Owned
Enter percentage: The percent of shares owned.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Name
Enter text: The full name of the shareholder.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Member of Board
Enter Y for a Yes response. Input N for No response. Indicates if the shareholder is a
member of the board of directors.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Percent Owned
Enter percentage: The percent of shares owned.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Name
Enter text: The full name of the shareholder.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Member of Board
Enter Y for a Yes response. Input N for No response. Indicates if the shareholder is a
member of the board of directors.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Percent Owned
Enter percentage: The percent of shares owned.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Name
Enter text: The full name of the shareholder.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Member of Board
Enter Y for a Yes response. Input N for No response. Indicates if the shareholder is a
member of the board of directors.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Percent Owned
Enter percentage: The percent of shares owned.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Name
Enter text: The full name of the shareholder.
ACORD 807 (2014/12) rev. 05-29-2014
Page 13 of 18
OWNERSHIP /
ORGANIZATION
STRUCTURE
Member of Board
Enter Y for a Yes response. Input N for No response. Indicates if the shareholder is a
member of the board of directors.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Percent Owned
Enter percentage: The percent of shares owned.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Name
Enter text: The full name of the shareholder.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Member of Board
Enter Y for a Yes response. Input N for No response. Indicates if the shareholder is a
member of the board of directors.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Percent Owned
Enter percentage: The percent of shares owned.
OWNERSHIP /
ORGANIZATION
STRUCTURE
Do All Shareholders That
Own 5% Or More Of the
Voting Shares Have a
Representative On the
Board of Directors? (Y / N)
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Do all shareholders that own 5% or more of the voting shares, either directly or beneficially,
have a representative on the board of directors?.
OWNERSHIP /
ORGANIZATION
STRUCTURE
If No Shareholders Own
More Than 5% Or More,
Please Initial Here:
Initial here: The named insured's initials.
OWNERSHIP /
ORGANIZATION
STRUCTURE
List Name of Parent
Company
Enter text: The name of the parent organization.
GENERAL INFORMATION
1. During the last five (5)
years, has the applicant or
any director, officer,
members of the board of
managers or any other
proposed insured been
involved in any claims,
lawsuits or administrative
proceedings?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
During the last specified number of years, has the applicant or any director, officer, members of
the board of managers or any other proposed insured been involved in any claims, lawsuits or
administrative proceedings?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether the applicant or any director, officer, member of the
board of managers or any other proposed insured has been involved in any claims, lawsuits or
administrative proceedings during the last specified number of years.
ACORD 807 (2014/12) rev. 05-29-2014
Page 14 of 18
GENERAL INFORMATION
2. Any changes in the board
of directors or senior
management in the last
three (3) years?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Any changes in the Board of Directors or senior management in the last specified number of
years?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether any changes to the board of directors or senior
management have been made in the last specified number of years.
GENERAL INFORMATION
3. During the last specified
number of years, has the
applicant completed or
agreed to, or is
contemplating within the
next 12 months; a merger,
acquisition or consolidation
with another entity?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
During the last specified number of years, has the applicant completed or agreed to, or is
contemplating within the next 12 months; a merger, acquisition or consolidation with another
entity?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether the applicant has, during the last specified number of
years, completed or agreed to, or is contemplating within next 12 months; a merger, acquisition
or consolidation with another entity. If YES, please also provide a financial statement from the
other entity.
GENERAL INFORMATION
4. During the last three (3)
years, has the applicant
completed or agreed to or is
contemplating within the
next 12 months any
registration for a public
offering or any private
placement of securities?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
During the last specified number of years, has the applicant completed or agreed to or is
contemplating within the next 12 months; any registration for a public offering or any private
placement of securities?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether the applicant has, during the last mandated number of
years, completed or agreed to, or is contemplating within the next 12 months; any registration
for a public offering or any private placement of securities.
GENERAL INFORMATION
5. During the last three (3)
years, has the applicant
completed or agreed to or is
contemplating within the
next 12 months; a
reorganization or
arrangement with creditors
under federal or state law?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
During the last specified number of years, has the applicant completed or agreed to or is
contemplating within the next 12 months; a reorganization or arrangement with creditors under
federal or state law?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether the applicant has, during the last mandated number of
years, completed or agreed to, or is contemplating within the next 12 months; a reorganization
or arrangement with creditors under federal or state law.
ACORD 807 (2014/12) rev. 05-29-2014
Page 15 of 18
Form Page 3
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
GENERAL INFORMATION
(continued)
6. Does the applicant or any
of its subsidiaries act as a
general partner in any
partnership or are involved
in any joint ventures?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does the applicant or any of its subsidiaries act as a general partner in any partnership or are
involved in any joint ventures?.
GENERAL INFORMATION
(continued)
Remarks
Enter text: An explanation as to whether the applicant or any of its subsidiaries act as a general
partner in any partnership or are involved in any joint ventures.
GENERAL INFORMATION
(continued)
7. Are any persons or
entities proposed for this
insurance aware of any fact,
circumstance, act, error,
omission, or situation which
may give rise to a claim that
would fall within the scope
of the proposed insurance?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are any persons or entities proposed for this insurance aware of any fact, circumstance, act,
error, omission, or situation which may give rise to a claim that would fall within the scope of the
proposed insurance?.
GENERAL INFORMATION
(continued)
If Yes, has the
policyholder or any insured
individual, given written
notice under the provisions
of any prior or current
insurance policy?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Has the policyholder or any insured individual given written notice under the provisions of any
prior or current insurance policy of specific facts or circumstances which might give rise to a
claim being made against any insured for any proposed insurance?.
GENERAL INFORMATION
(continued)
Remarks
Enter text: An explanation as to whether there are any persons or entities proposed for this
insurance, aware of any fact, circumstance, act, error, omission, or situation which may give rise
to a claim that would fall within the scope of the proposed insurance.
GENERAL INFORMATION
(continued)
8. Has any insurer refused,
cancelled, non-renewed, or
stated an intent to
non-renew your D&O
insurance? (Missouri
Applicants - Do not answer
this question)
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Has any insurer refused, cancelled, non-renewed, or stated an intent to non-renew your D&O
insurance? As used here, Missouri Applicants - Do not answer this question.
GENERAL INFORMATION
(continued)
Remarks
Enter text: An explanation as to whether any insurer has refused, cancelled, non-renewed, or
stated an intent to non-renew your D&O insurance.
ACORD 807 (2014/12) rev. 05-29-2014
Page 16 of 18
GENERAL INFORMATION
(continued)
9. Are any of the applicants
securities or those of its
subsidiaries publicly traded
or subject to public
reporting under the
Securities Exchange
Commission Act of 1934?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are any of the applicants' securities, or those of its subsidiaries publicly traded or subject to
public reporting under the Securities Exchange Commission Act of 1934?.
GENERAL INFORMATION
(continued)
Remarks
Enter text: An explanation as to whether any of the applicants' securities or those of its
subsidiaries, are publicly traded or subject to public reporting under the Securities Exchange
Commission Act of 1934.
GENERAL INFORMATION
(continued)
10. Has the applicant had a
breach of debt covenant or
loan agreement?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Has the applicant had a breach of debt covenant or loan agreement?.
GENERAL INFORMATION
(continued)
Remarks
Enter text: An explanation as to whether the applicant had a breach of debt covenant or loan
agreement.
GENERAL INFORMATION
(continued)
11. Does the applicant
provide any consulting
and/or professional
services?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does the applicant provide any consulting and/or professional services?.
GENERAL INFORMATION
(continued)
Remarks
Enter text: An explanation as to whether the applicant provides any consulting and/or
professional services.
REMARKS / ATTACHMENTS Resume(s)
Check the box (if applicable): Indicates a resume is attached.
REMARKS / ATTACHMENTS Warranty(ies)
Check the box (if applicable): Indicates a warranty is attached.
REMARKS / ATTACHMENTS Registration Statement(s)
Check the box (if applicable): Indicates a registration statement is attached.
REMARKS / ATTACHMENTS
Private Placement
Memoranda
Check the box (if applicable): Indicates a private placement memoranda is attached.
REMARKS / ATTACHMENTS Schedule of Shareholders
Check the box (if applicable): Indicates a schedule of shareholders is attached.
REMARKS / ATTACHMENTS Other
Check the box (if applicable): Indicates there are attachments to the application other than those
listed.
REMARKS / ATTACHMENTS Other Description
Enter text: The description of the attachment.
REMARKS / ATTACHMENTS Other
Check the box (if applicable): Indicates there are attachments to the application other than those
listed.
REMARKS / ATTACHMENTS Other Description
Enter text: The description of the attachment.
REMARKS / ATTACHMENTS Other
Check the box (if applicable): Indicates there are attachments to the application other than those
listed.
ACORD 807 (2014/12) rev. 05-29-2014
Page 17 of 18
REMARKS / ATTACHMENTS Other Description
Enter text: The description of the attachment.
REMARKS / ATTACHMENTS Remarks
Enter text: The remarks associated with the directors and officers line of business. Use this
section to list any additional, pertinent information that the underwriter should know about the
overall exposures of this risk. ACORD 101, Additional Remarks Schedule, may be attached if
more space is required.
SIGNATURE
Applicant's Name
Enter text: The named insured(s) as it / they will appear on the policy declarations page.
SIGNATURE
Applicant's Title
Enter text: The title of the individual in the organization or his relationship to the organization.
SIGNATURE SECTION
State Producer License
Number
Enter identifier: The State License Number of the producer. As used here, this is required in
Florida and Nebraska.
SIGNATURE
Applicant's Signature
Sign here: Accommodates the signature of the applicant or named insured. As used here, upon
completion of the full commercial lines application series, the insured should review the
applications and sign this form in the available space.
SIGNATURE
Date
Enter date: The date the form was signed by the named insured. (MM/DD/YYYY)
SIGNATURE
Producer's Signature
Sign here: Accommodates the signature of the authorized representative (e.g., producer, agent,
broker, etc.) of the company(ies) listed on the document. This is required in most states.
SIGNATURE
National Producer Number
Enter identifier: The National Producer Number (NPN) as defined in the National Insurance
Producer Registry (NIPR). Note: The NPN is not the same as the producer state license
number.
ACORD 807 (2014/12) rev. 05-29-2014
Page 18 of 18