DIRECTORS AND OFFICERS PROPOSTA DI POLIZZA
La presente proposta deve essere compilata dall`Amministratore o dal Sindaco della Societa` proponente
dotato di opportuni poteri . La firma della presente proposta non comparta alcun obbligo per
l`assicuratore ne` comporta alcuna copertura assicurativa .
This proposal form must be completed by a director or company secretary, and answered fully for a
quotation to be given. The completion and signature of this proposal form does not bind the Company or
Insurer to complete a contract of insurance.
If necessary, additional information should be provided on the Company’s letter headed paper.
Se necessario potete integrare le informazioni su carta intestata del Proponente .
1.
Name
of
proponente
Company/Nome
del
2.
Registered address/Indirizzo della sede
legale
3.
Year of establishment / Data Fondazione
4.
Legal status of Company / Tipo di societa`
Privately Owned (capitale riferibile a soggetti privati )
Publicly Owned (capitale riferibile a soggetti pubblici )
Charity or Not-for- Profit ( organizzazioni no- profit o caritatevoli )
5.
Nature of business/Tipo di attivita`
W. R. Berkley Insurance (Europe), Ltd is authorised and regulated by the Financial Services Authority.
Registered Office: 2nd floor, 40 Lime Street, London EC3M 7AW. Registered in England & Wales 4681277
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6.
Number of shareholders of the Company /Numero dei soci
7.
Percentage of shares held by directors of the Company/ percentuale di quote
detenuta dagli amministratori
8.
Full details of shareholders who own 10% or more of issued shares / Dettagli di tutti i soci con piu`
del 10% di quote 0 azioni
Shareholders - Azionista
9.
Is the Company listed on any Stock Exchange?La societa`
e` quotata ?
Percentage Owned
Percentuale posseduta
Yes
No
If so, please provide full details: Se si per favour fornire dettagli:
10.
Is the Company contemplating any offering or share issue in the next
12 months?La societa` ha emesso azioni negli ultimi 12 mesi ?
Yes
No
If so, please provide full details: Se si per favour fornire dettagli:
11.
Does the Company have any acquisition, tender offer or merger
pending or under consideration?La societa` ha in corso o sta
considerando alcuna fusione , acquisizione
Yes
No
W. R. Berkley Insurance (Europe), Ltd is authorised and regulated by the Financial Services Authority.
Registered Office: 2nd floor, 40 Lime Street, London EC3M 7AW. Registered in England & Wales 4681277
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If so, please provide full details: Se si per favour fornire dettagli:
12.
Is the Company aware of any proposal relating to its acquisition by
another organisation? La Societa` e` al corrente di intenzioni di
acquisizione da parte di alter organizzazioni?
Yes
No
Yes
No
Yes
No
If so, please provide full details: Se si per favour fornire dettagli:
13.
Have there been any acquisitions, disposals or created subsidiaries in
the past 12 months? Ci sono state acquisizioni o creazioni di societa`
collegate negli ultimi 12 mesi ?
If so, please provide full details: Se si per favour fornire dettagli:
14.
During the past five years, has either the capital structure or the
name of the Company changed?Negli ultimi 5 anni la struttura
societaria o il nome della societa` sono cambiati ?
If so, please provide full details: Se si per favour fornire dettagli:
W. R. Berkley Insurance (Europe), Ltd is authorised and regulated by the Financial Services Authority.
Registered Office: 2nd floor, 40 Lime Street, London EC3M 7AW. Registered in England & Wales 4681277
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Page 3 of 5
15.
If this proposal is not for a renewal by W. R. Berkley Insurance
(Europe), Ltd, does the Company currently have Directors &
Officers Liability in force? Nel caso in cui questa proposta non sia
riferita ad un rinnovo con W.R. Berkley Esiste al momento copertura
assicurativa D&O?
Yes
No
If so, please confirm: Se si confermare :
Insurer - Compagnia
Limit of Indemnity - Massimali
Policy Period – Periodo Assicurativo
Premium - Premio
16.
Has the Company ever been refused this type of insurance or had a similar Yes
insurance cancelled?
Il proponente ha mai avuto una polizza D&O cancellata o rifiutata ?
No
If so, please provide full details: Se si per favour fornire dettagli:
17.
Have any claims ever been made against any past or present
director, officer or employee of the Company or its subsidiaries?
Yes
Il proponente ha mai avuto richieste di risarcimento danni dirette ad
uno degli amministratori dirigenti o dipendenti della società ?
No
If so, please provide full details: Se si per favour fornire dettagli:
18.
Is the Company or any director, officer or employee aware, after
enquiry, of any circumstance or incident that may give rise to a Yes
claim? E` il Proponente o alcuno dei suoi dipendenti a conoscenza
di qualsiasi circostanza che potrebbe dare origine ad un sinistro o
richiesta di risarcimento danni ?
No
If so, please provide full details: Se si per favour fornire dettagli:
W. R. Berkley Insurance (Europe), Ltd is authorised and regulated by the Financial Services Authority.
Registered Office: 2nd floor, 40 Lime Street, London EC3M 7AW. Registered in England & Wales 4681277
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Page 4 of 5
Please complete questions 19-22 if cover is required for activities in North America
Da completare solo in caso di estensione a Nord America
19.
What is the total gross assets of the Company and its subsidiaries in
North America? Quale e` il valore delle attivita` della societa`
incluso le collegate in Nord America ?
20.
What is the total turnover of the Company and its subsidiaries
derived from North America? Quale e` il giro di affari totale delle
sedi in Nord America ?
21.
Does the Company or any of its subsidiaries have any Yes
shares traded in the United States of America?
Il proponente ha azioni scambiate in una borsa negli Stati
Uniti ?
No
If so, please state the percentage of total shares traded, and enclose a
copy of the latest 20-F filing or similar filing made to the USA
Regulatory Authorities.
Se si indicate il valore totale ed il numero delle azioni scambiate :
22.
Does the Company have any shares traded in the form of Yes
ADRs?
La Compagnia ha azioni scambiate in forma di ADR ?
No
DECLARATION
I/We declare that the contents of this proposal form are true and that I/we have not mis-stated or
suppressed any material facts. I/We agree that this proposal form together with any other information
supplied by me/us shall form the basis of any contract of insurance effected hereon. I/We undertake to
inform Insurers of any material alteration to these facts occurring before completion of the contract of
insurance.
Dichiaro che tutto quanto qui riportato corrisponde a verita` e che il rischio eventualmente assunto
dall`assicuratore lo e` sulla base di queste informazioni da me rilasciate .Se tali informazioni cambiano
ho il dovere di informare l`assicuratore prima della sottoscrizione del contratto assicurativo .
Please attach a copy of the most recent audited annual accounts for the Company and the latest interim
statement (if applicable). In allegato copia dei piu` recenti bilanci .
Signed/ Firma
Capacity / Posizione
Company / Società
Date
W. R. Berkley Insurance (Europe), Ltd is authorised and regulated by the Financial Services Authority.
Registered Office: 2nd floor, 40 Lime Street, London EC3M 7AW. Registered in England & Wales 4681277
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