Fillable APPLICATION COVER-PRO FINANCIAL PLANNER/CONSULTANT/ADVISER SUPPLEMENT (Philadelphia Insurance Companies)

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APPLICATION COVER-PRO FINANCIAL PLANNER/CONSULTANT/ADVISER SUPPLEMENT (Philadelphia Insurance Companies)

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PI-PLSP-FINSUPP 12/09
Page 1 of 5 Ed. 12/09
COVER-PRO
SM
APPLICATION
FINANCIAL PLANNER/CONSULTANT/ADVISER SUPPLEMENT
SUBMISSION REQUIREMENTS
Please attach a copy of the following for each Applicant seeking coverage:
• Most recent Form ADV, Part I and Part II including all supplements and/or any state regulatory filings.
Not Applicable
• A copy of sample Client Agree
ment
1. Full Name of the Applicant Firm:
2. Total assets under management: Current Fiscal Year $ Previous Fiscal Year $
Asset value of largest account: $
Total number of accounts:
Total number of clients:
Number of accounts/clients lost in the last twelve (12) months:
Value of accounts/clients lost in the last twelve (12) months: $
3. Please indicate all services provided by the Applicant and the percentage of total revenues derived
from such activity:
Financial Planning: % Property Management*: %
Investment Banking: % Tax Planning: %
Sub-Advisory **: % Broker Dealer Services: %
Tax Preparation: % Investment Advise: %
Other: Describe:
*
If property manag
ement services are performed does the Applicant have a real estate
agent/broker licen
se?
Yes No
** If sub-advisory services
are performed please advise the following:
a. Are any of the client’s for which Applicant is acting in a manager/officer capacity
experiencing poor financial stability, filing for or anticipate filing for bankruptcy, or
considering a merger or acquisition? Yes
No
If yes, provide the name of client(s).
b. If acting as temporary Officer does the Applicant have Directors and Officers coverage in
place? Yes No
N/A
4 a. For those accounts for which the Applicant acts as Investment Counselor or Adviser,
please provide a breakdown of assets under management, number of accounts and
number of clients that fall into each of the categories listed in the columns below. If you
do not provide such services, please indicate “not applicable”.
N/A
%
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PI-PLSP-FINSUPP 12/09
Page 2 of 5 Ed. 12/09
DISCRETIONARY ACCOUNTS:
Market Asset
Value
# of
Accounts
# of
Clients
ERISA Defined Benefit Plans $
ERISA Defined Contribution Plans $
HR 10 and IRA Plans $
Non-ERISA Pension and Employee Benefit Plans $
Mutual Funds (to which Applicant serves as
investment adviser or Sub-adviser)
$
Limited Partnerships (to which Applicant serves as
general partner, managing member, investment
adviser or sub-adviser)
$
Hedge Funds (to which Applicant serves as general
partner, managing member, investment adviser or
sub-adviser)
$
Private REITS (to which the Applicant serves as
investment adviser or sub-adviser)
$
All other accounts (including personal accounts) $
TOTAL BOOK VALUE OF ALL ACCOUNTS
$
4. b.
NON-DISCRETIONARY ACCOUNTS:
Market Asset
Value
# of
Accounts
# of
Clients
ERISA Defined Benefit Plans $
ERISA Defined Contribution Plans $
HR 10 and IRA Plans $
Non-ERISA Pension and Employee Benefit Plans $
Mutual Funds (to which Applicant serves as
investment adviser or Sub-adviser)
$
Limited Partnerships (to which Applicant serves as
general partner, managing member, investment
adviser or sub-adviser)
$
Hedge Funds (to which Applicant serves as general
partner, managing member, investment adviser or
sub-adviser)
$
Private REITS (to which the Applicant serves as
investment adviser or sub-adviser)
$
All other accounts (including personal accounts) $
TOTAL BOOK VALUE OF ALL ACCOUNTS
$
5. Are any client transactions executed by an in-house broker dealer? Yes No
6. Does the Applicant use outside or affiliated custodians, broker dealers or accounting
facilities?
Yes
No
a. If affiliated custodians, broker dealers or accounting facilities are used please supply
name of the entities in the space provided below:
7. Has the Applicant been inspected by either the SEC or State Regulatory Authority in the last
5 years?
Yes No
8. Does the Applicant have formal written procedures for each of the following:
a. to determine and document client investment goals and risk tolerance? Yes No
b. to explain and document client understanding of security investment risks? Yes No
c. for verifying suitability of client security purchases? Yes No
If yes, please provide a copy of the report along with management’s response.
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PI-PLSP-FINSUPP 12/09
Page 3 of 5 Ed. 12/09
9. If the Applicant provides Financial Planning services to clients, please answer the following
questions.
N/A
a. How many Financial Planning clients does the Applicant service?
b. Are the Financial Planning revenues fee generated? commission generated?
c. If commission generated, please provide percentage of revenues: %
10. Please provide the following:
Type of Revenue
Percentage of
Financial Planning
Revenue
a. fees for preparing financial plans %
b.
c.
d. commissions from derivatives, real estate, investment trust, unregistered security
sales
%
e. other product sales related to financial planning (describe product) %
f. tax planning and/or accounting service fees %
g. CPA or other accounting service fees %
h.
i. insurance planning fees %
j. retirement planning fees %
k. education planning fees %
l. daily cash management/bill paying services %
m. other services (describe) %
* If a percentage of Financial Planning Revenue is derived from
life/health/annuity/disability product sales advise if Applicant is a licensed
insurance agent or broker.
Yes
No
If you do not provide such services, please indicate “not applicable”.
estate planning fees
commissions from life/health/annuity/disability product sales*
%
%
%
commissions from mutual f
unds, stocks or bonds
Signature
The Unde
rsigned warrants that to the best of his/her knowledge and belief the statements set
forth herein are true. The Undersigned further declares that any occurrence or event that takes
place prior to the effective date of the insurance applied for which may render inaccurate, untrue,
or incomplete any statement made will immediately be reported in writing to the Underwriter. The
Underwriter may withdraw or modify any outstanding quotations and/or authorization or
agreement to bind the insurance. The Underwriter is hereby authorized to make any investigation
and inquiry in connection with the information, statements and disclosures provided in this
Application. The signing of this Application does not bind the Undersigned to purchase the
insurance, nor does the review of this Application
bind the insurance company to issue a policy. It is agreed that this Application shall be the basis
of the contract should a policy be issued. This Application will be attached and become a part of
the policy.
Name (Please Print/Type) Title (MUST BE SIGNED BY THE CHAIRMAN)
_________________________________________________
Signature Date
The above signed warrants that he/she is authorized and has the power to complete and execute
this Application, including the Warranty Statement on behalf of the Applicant and their respective
Directors, Officers or other insured persons.
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Section to be completed by Producer/Broker
Producer: Agency:
Agency Taxpayer ID or SS No.: Producer License No:
Address (Street, City, State, Zip) :
PI-PLSP-FINSUPP 12/09
Page 4 of 5 Ed. 12/09
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ADDITIONAL INFORMATION
This page may be used to provide additional information to any question on this application. Please
identify the question number to which you are referring.
__________________________________________________
Signature Date
PI-PLSP-FINSUPP 12/09
Page 5 of 5 Ed. 12/09
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APPLICATION COVER-PRO FINANCIAL PLANNERCONSULTANTADVISER SUPPLEMENT (Philadelphia Insurance Companies)

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Completed 7 November 2020

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