Venture Capital Asset Protection（一）.docVIP

Chubb Insurance Company of Canada APPLICATION for Venture Capital Asset Protection By completing this APPLICATION you are applying for coverage with Chubb Insurance Company of Canada (the Company) NOTICE: The Venture Capital Asset Protection policy for which this Application is made is written on a claims-made basis. Except where the laws of the Province of Quebec apply or as otherwise provided, this section of the policy will cover only “Claims first made against the Insured during the Policy Period”. Please read the policy carefully. Defence Costs Provision: Please note that the Defence Costs provision of this policy stipulates that the Limit Of Liability may be completely exhausted by the cost of legal defence. Any deductible may be similarly reduced or exhausted by Defence Costs. A. GENERAL INFORMATION Name of Applicant: Principal Address: City: Province: Postal Code: Web site Internet address (if applicable): http:// Please complete the Schedule Of Subsidiaries under Section D. Please complete the Schedule Of Limited partnerships under Section E. Please complete the Schedule Of Portfolio Companies under Section F. Name of Broker: Officer designated as agent of the Applicant and all Insured Persons to receive any and all notices from the Company or their authorized representative(s) concerning this insurance: Name of Officer/Partner: Title of Officer/Partner: Date Established: Business form: Corporation General Partnership Limited Partnership Limited Liability Company Other If incorporated, please complete the following: Province of incorporation: Total number of shareholders: Total number of shares outstanding: Total number of shares owned directly or beneficially by Directors or Officers: Please provide, on a separate sheet, the names and percent owned of any shareholders holding directly or beneficially 10% or more of the common stock. If none, please indicate. None Are there any other sec