董事及高级职员责任保险投保申请书

1、葷事及高级职员责任保险投保申请书一、投保公司资料1. 投保公司名称(n ame of propose r): 2. 公司，总咅旳也址(address of head office)： 3. 公司 注册国(country of registration): 4. 公司 设立 / 成立 口 期(date of incorporation/formation)： 5. (a)投保公司连续营业时间：(how long has the proposer continually earned on business?)(b) 投保公司及其子公司主莒业务：(state the principal busin

2、ess activities of the proposer and its subsidiaries)6. 投保之责任限额： (limit(s) of liability being requested)7. (a)请用附页列出投保公司所有子公司的名称、注册国、及投保公司的持股比例。(give a complete list of all subsidiaiy companies including country of registration and percentage owned by propose匚 please use attachment.)(b) 投保公司是否在美国设立/成

3、立任何子公司？ 是 否(does the proposer have any subsidiary(ies) incorporated/formed in the unitedstates of america?)(c) 投保公司所要求的董事及高级职员责任保险承保范鬧是否包含上述所列之每一子公司？ 是 否(is the proposer requesting directors and officers insurance for each subsidiary listed in (a) above?)若上述7(c) z答案为否，则请列出不拟投保z子公司名称。(if "no&quo

4、t; to question 7(c) please list those subsidiaries for which insurance is not being requested.)注：投保公司及其子公司，以下统称为投保公司(nb hereinafter the proposer and its subsidiaries shall be known as the "company.")&(a)请捉供最近一期年报中所述之投保公司(合并)总资产:(please provide total (consolidated) annual gross assets o

5、f the company from the most recent year end report)(b) 请提供最近一期年报中所述z投保公司(合并)全年总收入/营业额：(please provide total (consolidated) annual rcvcnucs/turnovcr of the company from the most recent year end report)(c) 请提供投保公司最近两年的(合并)总净值：(please provide the total (consolidated) net worth of the company for the pa

6、st two years)(d) 请提供投保公司最近两年(合并)总净利润：(please provide the total (consolidated) net income of the company for the past two years)9. 最近五年内：(a) 投保公司名称是否变更？ 是 否(the name of the proposer changed?)(b) 投保公司及其子公司是否曾发牛收购或合并案？ 是否(any acquisition or merger taken place of the proposer or any subsidiary occurred?

7、)(c) 有无子公司被出售或停止营业？ 是否(any subsidiary been sold or ceased trading?)(d) 投保公司是否有管理层收购、融资购并或其它资木结构变更？ 是否(the company undergone a management buy out, leveraged buy out or other change in capital structure of the parent company changed?)若上述任何问题之答复为是，请详细说明。10. 投保公司或其任何董事及高级职员现在是否有其它有效的董事及高级职员责任保 险？ 是否(doc

8、s the company or any director or officer have directors & officers liability insurance currently in force?)若上述答案为是，请针对以卜事项详细描述：(a) 保险人名称(insurer')： (b) 赔偿限额(indemnity limit): (c) 保单到期 h(expiry date)： (d) 保险费(premium): (e) 自 负额(retention(s): 11是否有任何保险人拒绝承保、终止或拒绝续保投保公司之董事及高级职员责任保 险？是 否(has the

9、 company ever had any insurer decline a proposal or cancel or refuse to renew a directors & officers liability insurance?)若答复为是，请详细说明:12 投保公司是：(a) 非公开发行z公司(privately held)? 是否(b) 公开发行之公司(权益或债券)是否(publicly traded (equity or debt)13若第12(b)z问题答复为是者，请就投保公司以下资料说明:每一上市之国家毎国家z证券交 易所/市场上市种类(直接，adr及 其级数，

10、otc)交易证券占所有发 行证券z比例证券种类(a) 投保公司是否于非止式证券市场上市？ 是否(is the proposer publicly listed on an unlisted securities market?)(b) 以其它方式交易其股票？ 是否(traded in any other way?)若答复为是，请说明：14 是否有任何子公司为公开发行z公司(权益或债券)15若第14问题之答复为是，请就每一子公司捉供以下资料:子公司名称设立或成立 之国家每一上市 之国家每一国家之证券交 易所/市场上市种类(直接，adr及其级数，otc)交易证券占所有发行证券 z比例及证券种类16

11、 请列出投保公司:(a) 全部股东人数(total number of shareholders)： (b) el发行之总股数(total number of shares issued): (c) 董事及高级职员所持有总股数(百分比，直接及受益)：(total number of shares (percentage) held by each director and officer of the company (both direct and beneficial)(d) 机构投资者所持有总股数(白分比)：(total number of shares (percentage) hel

12、d by institutional investors)(e) 所有持有投保公司或其上市子公司5%或以上股票者，请提供股票持有人名称及持股比例：(all security holders, holding a 5% or more ownership interest in the proposer, or any subsidiary that is publicly traded, giving the holder's name and the percentage held)持有人所属机构持股比例17.(a)投保公司或其任何子公司是否正考虑进行任何收购、公开收购、合并、买断或

13、其它影响股权结构之计划？ 是否(is the proposer or any subsidiary considering any acquisition, tender offer, merger, buyout or other change in equity structure?)(b)投保公司或其任何子公司是否知悉他公司或组织正考虑述行以投保公司或其任何子公司为标的任何收 购、公开收购、合并、买断或其它影响投保公司或其子公司股权结构z计 划？ 是 否(is the proposer or any subsidiary aware of whether any other compan

14、y or entity is considering an acquisition, tender offer, merger, buy-out or other change in equity structure of which the proposer or any subsidiaiy would be a target?)(c) 投保公司或其任何子公司是否有意在下一年度发行新的有价证券，或变更其目前证券上市状况z计 划？是否(is the proposer or any of its subsidiaries intending either a new public offeri

15、ng of securities (equity ordebt), or a change in the listing status of its existing securities, within the next year?)若上述任何问题之答复为是，请详细说明：l&(a)投保公司或其任何上市之子公司，于过去十二个月中，是否有董事及/或髙级管理人员辞职或被替 换？是否(have any directors and / or executive officers of the proposer or of any publicly tradedsubsidiary ofthe

16、proposer resigned or been replaced in the past 12 months)如果答复为是，请列出其姓名、职称及原i大i。(b)投保公司是否正在考虑于投保公司或其任何上市之子公司屮，更换或新增任何董事及高级职 员？是 否(is the company considering a replacement or addition of any directors and officers of the proposer or of any publicly traded subsidiary of the proposer?)如果答复为是，请列出其姓名、职务及原

17、因。19.(a)投保公司之外部审计机构为(who is the company external auditing firm?)(b)投保公司是否于过去三年内变更过其外部审计机构？ 是否(has the company changed its external auditing firm in the past three years?)如果答复为是，请回答于何时及其原囚。20投保公司于未来i二个月中，是否仃任何变更外部审计机构之计划？是 否(does the company have any plans to remove or replace its external auditor in

18、 the next 12 months)如果答复为是h请回答将置换之机构及原因。21(a)投保公司之所有收入确认方法是否均得到其外部审计机构无保留意见的批准？ 是否(have all revenue recognition practices of the company been approved by your existing external auditor, without qualification?) 如果答复为否，请详细说明。(b) 投保公司z外部审计机构于过去十二个刀中，是否曾建议投保公司变更收入确认方法或其它重大会计记账方法？是 否(have the company ext

19、ernal auditors recommended changes to the revenue recognition or other significant accounting practices in the past 12 months?)(c) 投保公司于过去十二个月中，是否变更或考虑变更收入确认方法或其它重大会计记账方法？毘否(has the company changed or considered changes to the revenue recognition or othersignificantaccounting practices in the past 1

20、2 months?)(d) 投保公司是否止考虑变更收入确认方法或其它重大会计记账方法？是 否(is the company considering changes to the revenue recognition or other significantaccounting practices)如果上述(b), (c), (d)之答复为是，请详细说明。22投保公司或其任何董事及/或高级职员是否于出资或参与任何合伙企业或特殊目的实 体？是 否(does the company or any of directors and/or officers thereof have any inter

21、ests in any partnerships or special puipose vehicles or entities?)如果答复为是，请详细说明。 是 否23. 投保公司是否曾对会计账h作追溯调整？(has the company ever restated its financial results.)如果答复为是，请详细说明。24. 投保公司预计是否会于未来十三个月内，从收入数字中扣除-笔大额非经常性损益，或对会计帐目做追溯 调整？ 是否(does the company anticipate having to take a significant one time char

22、ge to eainings, or restate earnings, within the next 13 months)如果答复为是，请详细说明。如果第24问题之答复为是，兹经双方当事人同意，除菲以批单特别批注扩展保障范围，木保单对于与 此事件相关z赔偿请求、调查、诉讼程序、起诉或指控所致z损失，不提供任何保障。(if "yes" to question 24, it is agreed that the proposed policy shall not provide any coverage for loss in connection with any cla

23、im, investigation, proceeding or action alleging or arising from such event, unless an endorsement is added to the proposed policy specifically extending coverage to such arising)25 投保公司关于董事、高级职员及雇员购买或出售公司股票，包含期权z行使，是否有明文规 定？是否(does the company have specific written corporate policies with respect t

24、o directors officers? and employees? ability to purchase or sell the company's stock, including the ability to exercise stock options)对于美国之保障如果投保公司需要保险人为在美国对其和被保险人提起之诉讼，或因其在美国的运营而在世界其它地区对其和 被保险人提出之诉讼提供保障，请回答下列第26-33之问题。26. q)请提供投保公司于美国之总毛资产： (please provide the total gross assets of the company

25、in the united states of america)(b) 请提供投保公司源自美国经营活动之总收入：(please provide the total revenues of the company derived from its activities in the united sates of america)(c) 于美国雇仰z员工总数以及员工人数最多的三个州：(total number of employees in the united states of america and three us states with the largest number of su

26、ch employees)27. 投保公司是否对位于或设立于美国的实体，拥有50%或以下的权益？是否(does the company have any ownership interest of 50% or less in any entity located or incorporated in the united states of america?)如果答复为是:(a) 请以附件形式提供该实体之名称、所属行业、为私有或上市公司，如为公开交易之上市公司，请说明 其证券之种类(债券或权益)及证券交易之交易所或市场之名称。(please provide in an attachment

27、the name of the entity, type of industry, whether public or private, and if publicly traded, type of securities (equity or debt) and the name of exchange or maiket on which such securities are traded.)(b) 于上述27之实体屮，投保公司是否派出任何董事在其董事会任职，或担任髙级管理人员职务？ 是 否(does the company have any representation on the

28、board of directors, or as an executive officer, on any entity listed in question 27(a) above)如果第27(b)的答复为是，请捉供该实体z名称，投保公司代表z姓名及职位。 (if “yes，to 27(b), please provide name of entity, name of individual and position)28. 投保公司是否于其财务报表中，将股票期权记录为费用？ 是否(does the company treat stock options as an expenses in

29、 its financial statements)29. 投保公司或其任何子公司是否持有于北美洲发行的任何股票、股份或债券？是否 (docs the proposer or any of its subsidiaries have any stock, shares or debentures in northamerica)是否如果答复为是的话:(i)该等股票、股份或债券是否公开交易？(are such stocks, shaies or debentures publicly traded) 如果答复为i是，请列出:实体z名称证券种类(权益 或债券)每国家之证券交 易所/市场上市种类(一

30、育接，adr及 其级数，otc)交易股数占所有已发行股木 之百分比30. 投保公司是否根据美国成文法、规则或规定设立内部审计委员会?是 否(docs the company have an internal audit committee pursuant to u.s. statutes, rules or regulations?)如果答复为否时，其原因为：如果答复为是，则(a) 该委员会每年是否召开四次以上之会议？ 是否(if “yesj does the audit committee meet more than four times a year?)(b) 于过去两年内，该委员会之

31、成员是否有辞职或被更换之情形？是否(if "yes,' has any member of the audit committee resigned or been replaced within thepast two years?)如果第30(b)问题之答复为是，该成员为何人，及其辞职或被更换的原因。31. 投保公司是否被要求必须遵循美国一般公认会计准则(gaap)是否(is the company required to follow u.s. generally accepted accounting principles (gaap)?)如果答复为是时，投保公司之财

32、务报衣是否通常均依照美国一般公认会计准则编 制？ 是否32投保公司或其任何其董事及髙级职员，现在或在过去五年内是否为美国证券管理委员会(sec)或美国税务署 (irs)强制执行行动的目标？ 是否(is the company or any director or officer of the company presently, or has the company or any director or officer of the company been in the past 5 years, the subject of a u.s. securities and exchange c

33、ommission (sec) enforcement action or a u.s. internal revenue service (irs) enforcement action?)如果答复为是，请详细说明。33美国证券交易委员会或美国税务署是否正对投保公司z董事、高级职员或雇员展开调查或口投保公司调阅上述人等之资料？是否(is the sec or irs investigating or requesting information from the company of any of the company's directors, officers or employ

34、ees)如果答复为是，请详细说明。以下问题请所有投保人填写。索赔情况34过去或现在是否有任何关丁(i)投保公司本身及/或(ii)欲以奥担任任何其它公司z董事或高级职员z身份纳 入此保险之个人，之未决之赔偿请求、诉讼或调查？是 否(has there been oris there now pending any claim(s) or actions against or investigation(s)of: (i) the company thereof; and/or (ii) any person proposed for insurance in his or her capacit

35、y as a director or officers of any company?)如果答复为是，请详细说明。35除特别说明外(请附详细资料)，投保公司之董事及髙级职员.首席法律顾问(或筹同于该职务人士)及风险经 理，对于此保险下可能合理地引起赔偿请求、调查或诉讼之任何行为、错谋及遗漏不知情或无任何信 息。是 否(the directors or officers of the company, the general counsel (or equivalent person) of the company and the risk manager of the company have

36、 no knowledge or information of any act, error or omission which could reasonably give rise to a claim, investigation or action under the proposed policy, except as follows: (attach complete details.)如果投保公司z葷事及高级职员、首席法律顾问(或等同于该职务人士)及风险经理，对于此保险下可能合 理地引起赔偿请求、调查或诉讼之任何行为、错谋及遗漏不知情或无任何信息者，请注明无：(if the dir

37、ectors or officers, the general counsel (or equivalent position) or the risk manager of the company have no such knowledge or information state "none")兹经双方当事人同意，与上述第34及第35之问题有关之赔偿请求、诉讼程序、诉讼、相关资料或与其有关事 由如事实存在，则由此等赔偿请求、诉讼程序、诉讼、相关资料或 引发之赔偿请求、诉讼程序或诉讼被排除于本保险之保障范围之外。(it is agreed that with respe

38、ct to questions 34 and 35 above, that if such claim, proceedings action, knowledge, information or involvement exists, then such claim, proceeding or action and any claim or action arising from such claim, proceeding, action，knowledge, information or involvement is excluded from the proposed coverag

39、e.)文件36.请提供投保公司以下文件z副本：(a) 最近一期么年报。(latest annual report)(b) 最近一期经审计之财务报告。(latest audited financials)(c) 最近一期z中报。(latest interim financials available)(d) (由公司秘书签发)之公司章程之补偿条款副本及公司之补偿合约。(copy (certified by organization secretary) of the indemnification provisions of the charter and the by-laws. also a

40、ttach a copy of organization indemnification agreement)(e) 最近一期注册会计师z管理建议书及投保公司z复函。(latest cpa management letter along with proposer's responses to any recommendations made therein)若投保公司有任何证券(权益或债券)于美国交易或上市者：最近一期向美国证监会(或相似的州或外国机关)提交的10k报告(latest 10k report filed with the securities and exchange

41、commission (sec) (or similar state or foreign agency)(g) 最近i匸个月所有向美国证监会(或相似的州或外国机关)提交的上市申请书(all registration statements filed with the sec (or similar state or foreign agency) within the last twelve months)(h) 由首席执行官和首席财务官签发之财务报表。最近卜二个月内所有年度股东人会的股东授权委托书声明及 通知。(copies of financial statements certifie

42、d by the ceo and cfo all proxy statements andnotices of annual meeting of stockholders within the last 12 months)兹同意投保公司将于下列文件备妥后，尽速提供予保险人，包括投保公司或其子公司不定期向任何监管证 券事务的本地或外国政府机关、监管机构或管理机构(包括但不限于美国证监会)各种上市申请书、年报或中 报。(it is agreed that the proposer will file with the insurer, as soon as it becomes availab

43、le, a copy of each registration statement and annual or interim report which the proposer or any subsidiary may from time to time file with any local or foreign governmental, regulatory body or agency that regulates securities (including but not limited to the us securities and exchange commission).)签署本投保书并不具约束投保公司购买此保险之效力声明本人兹代表金体被保人声明，经过调杳，在此附加投保书所作陈述及附件均属实，对于垂大事实并无 隐瞒或错误陈述。兹同意此投保帖连同任何附件、任何随z提交的资料、及任何提交或被要求提交的 所有其它资料，将构成订立有效保险合同z棊础。于签署木投保书后，保险合同生效前，据此投保书 提供的任何资料、陈述、表述或事实有亜大变更者，兹同意承担告知保险人z义务。(i declare on behalf of all insureds, after inquiry,