DETAILS OF PROPOSER

STATEMENT OF FACT

By signing this proposal the Assured confirms that the company:

• is an Israel registered limited company whose shares are not listed on any stock exchange
• has no subsidiaries that have shares listed on any stock exchange
• is not offering legal advice or advice on blockchain or similar technology*
• is not authorized or regulated by the Israel Securities Authority *
• is not a municipality, local authority, government related entity, Kibbutz, investment company or venture capitalist.*
• can fund operations and meet all short-term liabilities for the next 9 months if purchasing a 12 month policy period or 15 months if purchasing an 18 month policy period.
• has less than 50% of its total assets in the United States of America.
• has positive equity i.e. total assets greater than total liabilities. This is only to be confirmed if the company is not a Portfolio Company. A Portfolio Company is a company or entity in which a venture capital firm, buyout firm, Private Equity firm or other investment fund invests.
• in the last 12 months has generated a turnover that is equal to or under USD 25,000,000
• has not had a coin offering, as defined in the policy wording *
• are not using or anyway involved in crypto-currencies or crypto-tokens or any virtual or digital currency, asset or security which are disseminated using distributed ledger or blockchain or similar technology.*
• is not in any way involved with cannabis and/or cannabinoid*
• does not have Chinese shareholders holding more than 49% of the Company’s shares

* (including its subsidiaries)

I have read and confirmed the statement of facts.

NO CLAIMS DECLARATION

By signing this proposal the Assured confirms that the company and all of its subsidiaries:

• Has never had any official inquiry undertaken by any regulatory, governmental, professional or other authorized body into activities of any director or officer in any capacity.
• Have no pending claims against anyone for whom this insurance is intended which may fall within the scope of coverage afforded by any similar insurance presently or previously in effect.
• For whom this insurance is intended have not given notice under the provisions of any other previous or current similar insurance policy, of any facts or circumstances, which may give rise to a claim being made against any insured person.
• For whom this insurance is intended does not have any knowledge or information of any act, error, omission, fact or circumstance, which may give rise to a claim which may fall within the scope of this proposed insurance.

I hereby declare and confirm the above.

LIMIT OF LIABILITY

Gur's unique benefits:

• 10% side limit in addintion to the primary limit of your selection.
• For 18 month cover the premium is 140% instead of 150%.

PRIMARY Liability limit per incident and in the aggregate per period	Annual premium	Mark here	18 month premium	Mark here
USD 1,000,000	USD 2,450		USD 3,432
USD 2,000,000	USD 3,677		USD 5,148
USD 3,000,000	USD 4,803		USD 6,725
USD 4,000,000	USD 5,698		USD 7,977
USD 5,000,000	USD 6,360		USD 8,904

REINSTATEMENT OPTIONS

Reinstatement is an add on option that gives you additional limit for a different claim in case a claim exhausted the limits during the policy period.

For example:

If you selected $1M limits and the insurer will pay all the $1M due to specific claim the reinstatment will fill up the limits to $1M for another and totally different claim that will be filed in the same period.

Reinstatement options	Additional premium	Mark here
None	None
1 reinstatement	15% of annual premium
2 reinstatements	30% of annual premium

SUMMARY OF COVER

Liability Limit	Premium	Fee	Total Cost	Period	Reinstatements

I have read and agreed to the policy wording, terms and exclusions

DECLARATION & SIGNATURE

INSURANCE DETAILS

I would like the policy to start on:

You can choose cover to commence on any date within 30 days from when you sign this proposal form. Your commencement date cannot be more than 30 days prior to the date at which this form is signed and dated.

EEA EXPOSURE

Does the Company have any offices or subsidiaries located in the European Economic Area (EEA), or have any Insured Persons domiciled in the EEA?

Please refer to

https://worldpopulationreview.com/countries/eea-countries/

for a list of countries.

No Yes

Covid 19

Has the Covid 19 outbreak had, or could it have, a negative impact on your business? If yes, please give details and any mitigating measures put in place to address this.

No Yes

DECLARATION

I am authorized to complete this Proposal Form on behalf of all parties entitled to coverage under this insurance.

Gur's financial deparatment will be in touch with you for payment procces.
The payment must be made in one payment by a bank transfer to a UK bank account within 60 days.

I have read and agreed to the digital purchase of the policy. I have read and agreed to the policy Wording Directors & Officers Liability