Welcome to Holman Insurance Brokers on-line Directors & Officers Insurance quick quote page. Please ensure you complete the form as accurately as possible in order to ensure the best possible estimate. If you would rather speak to one of our sales representatives, please call us at (905) 886-5630 or 1-800-567-1279.

Completion of this form is for informational purposes only, and is just an estimate.
This WILL NOT result in a new policy, or change to an existing policy.

* Required Fields

Contact Information
Company Name*
Contact First Name*
Address*
Contact Last Name*
City*
Phone*
Province*
Phone 2
Postal Code*
Fax
Web Site
E-Mail*
Please specify your preferred method of contact:
Phone Email
Insurance Information
Are you presently insured? If yes, what company?* (enter "none" if answer is no)
Policy Number* (enter "none" if you do not have a policy number)
Expiry Date
What is your current annual premium?
$
Why are you looking for a new insurer or broker?
Stock Ownership Information
Number of voting stock shareholders:
Percentage of voting shares owned by directors and officers
Name and percentage of holdings of any shareholder who owns 10% or more of the voting shares:
Name Percentage
Is the corporation or any of its subsidaries publicly traded?
Yes No
If yes, on what exchange?
Please provide the price range for the stock over the last 12 months:
High $      Low $      Current $
Structural Changes
Is the Corporation presently involved in or considering any aquisitions or mergers?
Yes No
Is the Corporation presently involved in or considering any offering of securities?
Yes No
In the past 24 months, has the Corporation been involved in any offerings of securities?
Yes No

If yes to any of the above, please provide details:
International Exposure
At the date of application, list the following:
Canada
USA
Other
Percentage of corporation assets in:
Percentage of corporation shares held in:
Percentage of corporation sales made in:
Percentage of corporation employees in:
Does the corporation plan to expand its exposure in the next 12 months?
Yes No
Financial Information
Is the Corporation currently, or has it in the past 3 years been in arrears of its payments of monies payable to Revenue Canada or the provincial ministries of revenue?
Yes No
Is the Corporation currently, or has it at any time during the past 3 years sought protection under the "Companies Creditors Arrangement Act" or does it anticipate seeking such protection in the next 12 months?
Yes No
Is the Corporation currently, or has it at any time during the past 3 years been in a breach of any of its debt covenants, loan agreements, contractual obligations, or does it anticipate any such breach occuring within the next 12 months?
Yes No
Does the Corporation derive more than 25% of its annual revenue from one customer?
Yes No

If yes to any of the above, please provide details:
Prior D&O Insurance
Has any similar insurance on behalf of the Corporation or its directors and officers been declined, cancelled or renewal thereof refused?
Yes No
Have any claims, or facts or circumstances which might reasonably give rise to a claim, been reported to the current or previous directors and officers liability insurance carrier(s)?
Yes No

If yes to any of the above, please provide details:
Previous Director and Officer Liability Insurance:
Insurer(s) Expiration Date Limit Retention
Past Activities
Has the Corporation or any of the directors or officers, whether as executives of the corporation or any other corporation, been the subject of any:
actions, proceedings or investigations based upon or arising out of an alleged violation of any securities law or regulation, anti trust law or restrictive trading law or regulation?
Yes No
insolvency and/or bankruptcy proceedings?
Yes No
actions involving directors and officers other than those listed above?
Yes No

If yes to any of the above, please provide details:
Prior Knowledge
Are there now pending any claims against any director or officer?
Yes No
Does any director or officer have knowledge or information of any fact or circumstance which might give rise to a claim?
Yes No

If yes to any of the above, please provide details:
Additional Comments



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Directors & Officers Quote