D&O Application - The Roots Cannabis Insurance

Organization Information

Business Name

List and describe all entities in which the Applicant’s ownership interest is 50% or greater or which the Applicant has management control:

Number of Entities over which you have control

Entity 1

Entity 1 Name

% Owned

Year Started

Description of Operations

Entity Type†

Entity 2

Entity 2 Name

% Owned

Year Started

Description of Operations

Entity Type†

Entity 3

Entity 3 Name

% Owned

Year Started

Description of Operations

Entity Type†

Please provide a schedule of all entities in which the Applicant's ownership is 50% or greater or which the applicant has management control. Include the entity name, % owned, year started, description of operations, and entity type.

†Entity Type: FP=For-Profit; GP=General Partnership; LP=Limited Partnership; LLC=Limited Liability Company

In the next 12 months (or during the past 24 months) is the Applicant contemplating (or has the Applicant completed or been in the process of completing) the following:

Any actual or proposed merger, acquisition, or divestiture?

Yes

No

Any creation of a new business, subsidiary, or division?

Yes

No

Any registration for a public offering or a private placement of securities?

Yes

No

Any reorganization or arrangement with creditors under federal or state law?

Yes

No

Any branch, location, facility, office, or subsidiary closings, consolidations, or layoffs?

Yes

No