Fill - Free fillable APPLICATION FOR FIDUCIARY LIABILITY COVERAGE PART (Risk Placement Services, Inc.) PDF form

MP 6004 06 14

Includes copyrighted material of the Insurance Services Office, Inc., with its

permission.

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APPLICATION FOR FIDUCIARY LIABILITY

COVERAGE PART

THIS APPLICATION IS FOR A CLAIMS-MADE POLICY. "CLAIMS" MUST BE FIRST MADE AGAINST

AN "INSURED PERSON" DURING THE "POLICY PERIOD" OR ANY APPLICABLE EXTENDED

REPORTING PERIOD, AND REPORTED TO US AS SOON AS PRACTICABLE DURING THE "POLICY

PERIOD", ANY SUBSEQUENT RENEWAL OF THE POLICY OR ANY APPLICABLE EXTENDED

REPORTING PERIOD. THE INSURANCE FOR WHICH THIS APPLICATION IS MADE APPLIES ONLY IF

THE "WRONGFUL ACT" OUT OF WHICH THE "CLAIM" AROSE OCCURRED ON OR AFTER THE

RETROACTIVE DATE, IF ANY, SHOWN IN THE DECLARATIONS, AND BEFORE THE END OF THE

"POLICY PERIOD". "DEFENSE EXPENSES" ARE PAYABLE WITHIN, NOT IN ADDITION TO, THE LIMIT

OF LIABILITY.

SECTION I – GENERAL INFORMATION

Named Organization (Applicant):

Mailing Address:

Phone Number: Fax Number:

Web Site: E-Mail Address:

State Of Incorporation

(if applicable):

Date Of Incorporation

(if applicable):

Federal Employer Identification Number (FEIN): Nature Of Business:

SECTION II – FORM OF ORGANIZATION

Type Of Business:

Individual Partnership Corporation

Joint Venture LLC

Other (Please describe):

Has the Applicant been involved in any merger, consolidation or

acquisition with any other organization within the last three years?

Yes No

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SECTION III – COVERAGE REQUESTED

A. Limit Of Liability: $

Deductible

Amount:

$ C. Policy Period

From:

To:

SECTION IV – LIST OF PLANS FOR WHICH COVERAGE IS REQUESTED

Type* Name Of Plan Total Assets Trustee/Plan Administrator

No. Of

Partici-

pants

Total Assets of all plans: $ Total no. of participants for

all plans:

*Type: DB = Defined Benefit, DC = Defined Contri-

bution,

E = ESOP, P = Pension, W = Welfare, O = Other

1. Are all plans in compliance with regard to eligibility, participation, vesting and

funding of the Employee Retirement Security Act of 1974 (ERISA) or any other

similar law?

Yes No

If No, please explain:

2. Does any plan currently have a funding deficiency?

If Yes, please explain: Yes No

re the Defined Benefit plans adequately funded as attested to by an actuary?

If No, please explain: Yes No

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4. Is the Applicant delinquent in contributing to any plan?

If Yes, please indicate which plans and provide details: Yes No

5. Is any plan invested in employer securities?

If Yes, please indicate which plans: Yes No

6. Is any plan a multiple employer plan?

If Yes, please indicate which plans: Yes No

7. In the past three years, has any plan been consolidated or merged with another

plan?

Yes No

If Yes, please indicate which plans:

8. Has any plan or portion of any plan for which coverage is requested been sold,

transferred or terminated?

Yes No

If Yes, please provide details:

9. In the past three years, has any plan experienced a reduction in benefits?

If Yes, please indicate which plans: Yes No

10. In the past three years, has any plan applied for approval of a plan amendment?

If Yes, please indicate which plans: Yes No

11. Does the Applicant plan on terminating, suspending or merging any plans within

the next 12 months?

Yes No

If Yes, please indicate which plans and provide details:

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12. Is there an ERISA fidelity bond coverage currently in force with another insurer

for all the plans proposed for coverage?

Yes No

If Yes, please provide details below:

Insurer Limit Premium

$ $

13. If any plan is an Employee Stock Ownership Plan, please provide the following information:

a. Plan Name:

b. Date that the Plan was established:

c. Percentage of the Employer Sponsor's common stock

held by the Plan:

d. Is the stock publicly traded on an exchange? Yes No

e. If the answer to d. is No, how is the stock valued and how often is it valued? Provide details below:

f. Is an acquisition loan currently being paid off? Yes No

g. If the answer to f. is Yes, please provide the original amount of the loan and the loan's outstanding

balance below:

(1) Original amount of loan: $

(2) Outstanding balance of loan: $

SECTION V – PAST ACTIVITIES

1. Within the last three years, has the Applicant, any subsidiary of the Applicant,

any past or present Director, Officer, Employee or Trustee, or any past or

present person or entity acting as fiduciary, been involved in a claim or suit

regarding the violation of ERISA or any similar law?

Yes No

If Yes, please explain:

2. Within the last three years, has the Applicant, any subsidiary of the Applicant,

any past or present Director, Officer, Employee or Trustee, or any past or

present person or entity acting as fiduciary, been involved in any inquiry or

investigation or received a communication regarding the violation of ERISA or

any similar law?

Yes No

If Yes, please explain:

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3. Does the Director, Officer, or Trustee know of any fact, circumstance or situation

involving the violation of ERISA or any similar law by the Applicant, any

subsidiary of the Applicant, any past or present Director, Officer, Employee or

Trustee, or any past or present person or entity acting as fiduciary that could

give rise to a future claim or suit?

Yes No

If Yes, please explain:

It is understood and agreed that if any such claim exists, or any such facts or circumstances exist

which could give rise to a claim, then those claims and any other claims arising from such facts or

circumstances are excluded from the proposed coverage.

SECTION VI – PLAN MANAGEMENT

1. Are any Directors, Officers or Employees of the Applicant trustees of any of the

plans?

If Yes, please provide names of persons and plan(s):

Yes No

Name Of Director, Officer Or Employee Name Of Plan(s)

2. Does any plan employ outside consulting services such as investment, actuarial,

accounting, legal or administrative services?

If Yes, please provide a complete description of the services, name of consultant

and name of plan(s):

Yes No

Description Of Services Name Of Consultant Name Of Plan(s)

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SECTION VII – PRIOR INSURANCE

1. Has the Applicant previously held, or does it now have, any Fiduciary Liability

coverage or any similar insurance?

Yes No

If Yes, please provide the following details:

Name Of Insurer:

Policy Period Limit Of Liability: $

From: Retention: $

To: Premium: $

Name Of Insurer:

Policy Period Limit Of Liability: $

From: Retention: $

To: Premium: $

Name Of Insurer:

Policy Period Limit Of Liability: $

From: Retention: $

To: Premium: $

2. Has any insurance been cancelled or nonrenewed in the past 5 years?

(This questions is not applicable in Missouri)

If Yes, please provide the reason for cancellation or nonrenewal: Yes No

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SECTION VIII – ADDITIONAL REQUIRED APPLICATION MATERIALS

As attachments to this Application, please include the following (where applicable):

 Most recent Form 5500(s), including Schedule B

 CP

-audited report for each plan

 Actuarial report for each plan

 Most recent Annual Report

 Latest available interim financial statements

NOTICE TO APPLICANT – PLEASE READ CAREFULLY

FOR THE PURPOSE OF THIS APPLICATION, THE UNDERSIGNED AUTHORIZED OFFICER OF THE

NAMED ORGANIZATION DECLARES THAT TO THE BEST OF HIS/HER KNOWLEDGE THE STATEMENTS

HEREIN ARE TRUE AND COMPLETE. THE INSURER IS AUTHORIZED TO MAKE ANY INQUIRY IN CON-

NECTION WITH THIS APPLICATION. SIGNING THIS APPLICATION DOES NOT BIND THE INSURER TO

ISSUE, OR THE APPLICANT TO PURCHASE, ANY INSURANCE POLICY.

THE INFORMATION CONTAINED IN AND SUBMITTED WITH THIS APPLICATION IS ON FILE WITH THE

INSURER. THIS APPLICATION WILL BECOME A PART OF SUCH POLICY IF ISSUED. THE INSURER WILL

HAVE RELIED UPON THIS APPLICATION AND ATTACHMENTS IN ISSUING THIS COVERAGE PART.

IF THE INFORMATION IN THIS APPLICATION MATERIALLY CHANGES PRIOR TO THE EFFECTIVE DATE

OF THE POLICY, THE APPLICANT WILL NOTIFY THE INSURER, WHO MAY MODIFY OR WITHDRAW THE

QUOTATION.

THE UNDERSIGNED DECLARES THAT THE INDIVIDUALS AND ORGANIZATIONS PROPOSED FOR THIS

INSURANCE HAVE BEEN NOTIFIED THAT:

A. THIS POLICY APPLIES ONLY TO "CLAIMS" FIRST MADE OR DEEMED MADE AGAINST THE

"INSURED" DURING THE "POLICY PERIOD" AND THE BASIC EXTENDED REPORTING PERIOD;

AND

B. THE LIMIT OF LIABILITY IS REDUCED BY AMOUNTS INCURRED AS "DEFENSE EXPENSES" AND

SUCH EXPENSES WILL BE SUBJECT TO THE DEDUCTIBLE

MOUNT.

(WORDS WITHIN QUOTATION MARKS ARE DEFINED IN THE INSURANCE COVERAGE FORM.)

FRAUD STATEMENT

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly

presents false information in an application for insurance is guilty of a crime and may be subject to fines and

confinement in prison.

FRAUD STATEMENT TO ALABAMA APPLICANTS

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowing-

ly presents false information in an application for insurance is guilty of a crime and may be subject to restitution

fines or confinement in prison, or any combination thereof.

FRAUD STATEMENT TO ARKANSAS APPLICANTS

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly

presents false information in an application for insurance is guilty of a crime and may be subject to fines and

confinement in prison.

FRAUD STATEMENT TO COLORADO APPLICANTS

It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance compa-

ny for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment,

fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who

knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the

purpose of defrauding or attempting to defraud the policyholder or claimant with regard to settlement or award

payable from insurance proceeds shall be reported to the Colorado division of insurance within the department

of regulatory agencies.

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FRAUD STATEMENT TO DISTRICT OF COLUMBIA APPLICANTS

WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding

the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny

insurance benefits if false information materially related to a claim was provided by the applicant.

FRAUD STATEMENT TO FLORIDA APPLICANTS

Any person who knowingly, and with intent to injure, defraud, or deceive any insurer files a statement of claim

or an application containing any false, incomplete or misleading information is guilty of a felony of the third

degree.

FRAUD STATEMENT TO KENTUCKY APPLICANTS

Any person who knowingly and with intent to defraud any insurance company or other person files an applica-

tion for insurance containing any materially false information, or conceals, for the purpose of misleading, infor-

mation concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.

FRAUD STATEMENT TO LOUISIANA APPLICANTS

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly

presents false information in an application for insurance is guilty of a crime and may be subject to fines and

confinement in prison.

FRAUD STATEMENT TO MAINE APPLICANTS

It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the

purpose of defrauding the company. Penalties may include imprisonment, fines, or a denial of insurance benefits.

FRAUD STATEMENT TO MARYLAND APPLICANTS

Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or

who knowingly and willfully presents false information in an application for insurance is guilty of a crime and

may be subject to fines and confinement in prison.

FRAUD STATEMENT TO NEW JERSEY APPLICANTS

Any person who includes any false or misleading information on an application for an insurance policy is subject

to criminal and civil penalties.

FRAUD STATEMENT TO NEW MEXICO APPLICANTS

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly

presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and

criminal penalties.

FRAUD STATEMENT TO NEW YORK APPLICANTS

Any person who knowingly and with intent to defraud any insurance company or other person files an applica-

tion for insurance or statement of claim containing any materially false information, or conceals for the purpose of

misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a

crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the

claim for each such violation.

FRAUD STATEMENT TO OHIO APPLICANTS

Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an

application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

FRAUD STATEMENT TO OKLAHOMA APPLICANTS

WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any

claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty

of a felony.

FRAUD STATEMENT TO OREGON APPLICANTS

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly

presents materially false information in an application for insurance may be guilty of a crime and may be subject

to fines and confinement in prison.

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FRAUD STATEMENT TO PENNSYLVANIA APPLICANTS

Any person who knowingly and with intent to defraud any insurance company or other person files an applica-

tion for insurance or statement of claim containing any materially false information, or conceals for the purpose of

misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a

crime and subjects such person to criminal and civil penalties.

FRAUD STATEMENT TO RHODE ISLAND APPLICANTS

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly

presents false information in an application for insurance, including failing to disclose whether the applicant or

applicants have been convicted of any degree of the crime of arson, is guilty of a crime and may be subject to fines

and confinement in prison.

FRAUD STATEMENT TO TENNESSEE APPLICANTS

It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the

purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

FRAUD STATEMENT TO VERMONT APPLICANTS

Any person who, knowingly and with intent to defraud any insurance company or other person, files an applica-

tion for insurance or statement of claim containing any materially false information, or conceals for the purpose of

misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which may be

a crime and subjects such person to criminal and civil penalties.

FRAUD STATEMENT TO VIRGINIA APPLICANTS

It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the

purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

FRAUD STATEMENT TO WASHINGTON APPLICANTS

It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the

purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

FRAUD STATEMENT TO WEST VIRGINIA APPLICANTS

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly

presents false information in an application for insurance is guilty of a crime and may be subject to fines and

confinement in prison.

NOTE:

This Application must be signed by the Chairman and/or President of the Named Organization acting as

the authorized Agent of the Applicant applying for this insurance.

Printed Name of Chairman and/or President:

Signature of Chairman and/or President:

Title:

Date:

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