Fillable APPLICATION FOR FINANCIAL ADVISORS PROFESSIONAL LIABILITY INSURANCE NEW (RT Specialty)

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APPLICATION FOR FINANCIAL ADVISORS PROFESSIONAL LIABILITY INSURANCE NEW (RT Specialty)

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FP3003-01 12/07
APPLICATION FOR FINANCIAL ADVISORS PROFESSIONAL LIABILITY INSURANCE
NEW RENEWAL
Please return this page and the following items with your application materials:
Completed, dated and signed application.
Form ADV Part I, unless the Applicant has filed electronically with IARD.
NOTE Part I must be a current and accurate disclosure of the Applicant.
Form ADV Part II and all Schedules, unless the Applicant has filed electronically with IARD.
NOTE Part II must be a current and accurate disclosure of the Applicant.
Sample client contract(s) for each professional service rendered.
A copy of any regulatory audits performed in the last three (3) years and the Applicants response. Renewal
policyholders do not need to include audits previously submitted.
Balance Sheet and Income Statement (unaudited is acceptable).
ATTACHED DETAILS ON A SEPARATE SHEET IF:
Yes answer on Question 6., 7. and 8. Claim(s), Complaint or Proceedings
Yes answer on Question 9. Conflicts of Interest
Yes answer on Question 17.
Yes answer on Question 18. Disclosure Events
Yes answer on Question 22. Public Clients
NEW BUSINESS APPLICANTS ONLY:
If the Applicant wants prior acts coverage and has maintained continuous claims made coverage, attach a
Certificate of Insurance for current coverage and a coverage synopsis or a copy of the current declarations, policy
and endorsements.
Attachment for Questions 24 (a) and (b).
RETURN THIS PAGE WITH THE APPLICATION TO YOUR INSURANCE BROKER
Submit Application
FP3003-01 12/07 Page 1 of 5
APPLICATION FOR FINANCIAL ADVISORS
PROFESSIONAL LIABILITY INSURANCE
Notice: The policy for which application is made applies only to ³Claims´ first made against the Insured during the "Policy
Period" RUZLWKLQVL[W\GD\VDIWHUWKHH[SLUDWLRQRIWKH³Policy PHULRG´XQOHVVWKHExtended Reporting Period is exercised.
The limits of liability shall be reduced by ´&ODLPV Expenses´ and "Claims Expenses" are subject to the deductible.
Full Legal Name of Applicant
Principal business address
Telephone Fax
Email Web Site
1. List all employed (W-2) financial advisors. CPA firms should list only those that provide financial planning/investment
advisory services. Independent Contractors (1099) are not covered under policy and require separate applications or,
if requested, can be added as additional insureds.
Name of All Employed
Financial Advisors
Professional
Designations
FINRA
Number
FPA NAPFA Garrett
Network
BAM FI360 Other
Assocations
2. List the names of any independent contractors (non-employees) giving investment advice on behalf of the Applicant:
If None, check here
Does the Applicant want coverage for the listed independent contractors?................................................. Yes No
3. FORM ADV DISCLOSURES
(a) Is tKH$SSOLFDQW¶VForm ADV Part I as filed and dated on the SEC IARD a current and
accurate disclosure of Applicant as of the date of this application? If not SEC IARD filed,
provide complete Form ADV Part I in paper format.
Yes No
Not IARD filed
(b) Is WKH$SSOLFDQW¶VForm ADV Part II including schedules as filed and dated on the SEC IARD
a current and accurate disclosure of Applicant as of the date of this application? If not SEC
IARD filed, provide complete Form ADV Part II in paper format.
Yes No
Not IARD filed
(c) Does the Applicant agree to notify the Company of any change to facts presented in the
Application between the date of Application and the effective date of coverage?
Yes No
4. List all Professional Liability Insurance currently carried (e.g. accountants, tax preparation, group broker-dealer, life
agent).
Insurer Limits of Liability Deductible Type of
Insurance
Policy Period Retroactive
Date
5. REQUESTED LIMITS AND DEDUCTIBLES
PER CLAIM/AGGREGATE LIMITS REQUESTED DEDUCTIBLE REQUESTED
$ 100,000/$ 200,000 $ 1,000,000/$2,000,000 $1,000 $15,000
$ 250,000/$500,000 $ 2,000,000/$2,000,000 $2,500 $20,000
$ 500,000/$1,000,000 Higher Limits: $5,000 $25,000
$ 1,000,000/$1,000,000 $10,000 $50,000
THE COMPANY DOES NOT GUARANTEE TO OFFER ANY OF THE ABOVE LIMITS AND/OR DEDUCTIBLES.
6. Has any Professional Liability claim(s), complaint or proceeding been made against the Applicant or any person or
organization proposed for this insurance or any predecessor organization? .............................................. Yes No
If Yes, provide details on a separate sheet.
7. Is (are) any person(s) or organization(s) proposed for this insurance aware of any fact, error, omission, circumstance
or situation that might provide grounds for any claim under the proposed insurance?................................
Yes No
If Yes, provide details on a separate sheet.
FP3003-01 12/07 Page 2 of 5
8. Has the Applicant and/or any of its directors, officers and/or employees, its predecessors, subsidiaries, affiliates,
employees and/or any other person or organization proposed for this insurance been involved in or have knowledge of
any pending or completed governmental regulatory, investigative or administrative proceedings? ............
Yes No
If Yes, provide details on a separate sheet.
9. CONFLICTS OF INTEREST
By attachment provide explanation of any Yes response.
(a) Does the Applicant or any or its partners, officers, directors, employees or associated professionals:
(i) Act as both trustee and advisor to any client? Yes No
(ii) Advise clients to invest in any enterprise in which any firm member has more than a 5%
ownership interest?
Yes No
(iii) Advise clients to invest in any enterprise in which another client has more than a 5%
ownership interest?
Yes No
(iv) Act as advisor to an organization in which the Applicant its members or associated
persons has more than a 5% ownership interest?
Yes No
(b) Do any of the Applicants partners, officers, directors, employees or associated professionals have more than a
5% ownership or act as a director, officer, an employee or act in any position of control for any organization in
which clients are solicited to invest?...................................................................................................... Yes No
(c) Is any person proposed for insurance under this application a director, an officer, an employee, or in a position of
control for any organization or enterprise including all subsidiaries and affiliates which is also an advisory client?
............................................................................................................................................................... Yes No
(d) Is the Applicant or any or its partners, officers, directors, employees or associated professionals a CPA?
............................................................................................................................................................... Yes No
If, Yes, do any such persons perform attest work/consulting services for any accounting client who is an advisory
client? .................................................................................................................................................... Yes No
10. Does the Applicant use a Compliance Attorney or Consultant?................................................................... Yes No
If Yes, provide the name of such attorney and/or consultant:
11. Provide gross annual revenues derived from financial planning, advisory activities, commissions and/or product sales.
Do not include professional accounting services revenues unless the Applicant wants coverage for tax preparation.
Year Annual Total Gross
Revenues (100%)
% Fee Only
Revenues
% Commission
Revenues
No. of Financial
Advisors
Last Year $ % %
Present Year $ % %
Projected for Next Year $ % %
12. Provide professional services by approximate percentage. Must equal 100%. Indicate all services provided by the
Applicant regardless of whether the revenues are included in Question No. 11.
% NATURE OF PRACTICE % NATURE OF PRACTICE
Modular/Comprehensive Financial Plan
Preparation/Advice
Timing Services
Divorce Financial Consulting Tax Preparation
Discretionary Asset Management (LPOA) Accounting Services Other Than Tax Preparation
Non-Discretionary Asset Management (LPOA
with Prior Consent)
Third Party Pension Administration
Asset Monitoring (No Limited Power of Attorney
to Direct Trades)
Hourly Advice
Investment Management Consulting (No LPOA) Wrap Accounts
Product Sales Based On Financial Plan Referral To Third Party Managers
Product Sales Not Based On Financial Plan Other:
FP3003-01 12/07 Page 3 of 5
13. As an advisor, does the Applicant provide advice on, recommend or use alternative investments?...........
Yes No
If Yes, provide the percentage of the Applicants total practice advice and/or portfolio use that the following alternative
investments represent to the total advice and/or assets managed. Do not include investments that are used within a
mutual fund.
% Type Of Investment % Type Of Investment
Private Placements General or Limited Partnerships
Hedge Funds/Fund of Hedge Funds Foreign Securities Excluding $'5¶V
Mortgages, mortgage pools, mortgage
backed securities
REITS Privately Traded
Commodity Futures Promissory Notes
Unrated Bonds Tangibles (gold, silver, collectibles, coins, etc.)
Investment Related Real Estate Derivative Instruments
Options Contracts Other:
Unregistered Securities
14. Does the Applicant receive commissions? .................................................................................................. Yes No
If Yes, provide a breakdown of total commission income by percent. Must equal 100%
% Type Of Product % Type Of Product
Mutual Funds Promissory Notes/Leases/Receivables
Variable Annuities Private Placements
Life/Health/Disability/Accident Sales/Long
Term Care
REITS other than REIT Mutual Funds
Viatical Agreements/Senior Settlements/Life
Settlements
General or Limited Partnerships
Listed Stocks Unregistered Securities
Unlisted Stocks ForeLJQ6HFXULWLHV$'5¶6
Investment Grade Bonds Hedge Funds or Fund of Hedge Funds
Junk Bonds 2SWLRQV)XWXUHV7DQJLEOHV&02¶V'HULYDWLYHV
15. What percentage of WKH $SSOLFDQW¶V revenue is derived from professional entertainers, celebrities, athletes and
musicians? % If None, check here
16. Does the Applicant provide personal management services (e.g. sports management or bill paying, etc.)
to any client? ................................................................................................................................................ Yes No
17. (a) Is any advisory client an investment company (mutual fund), REIT, limited partnership or private placement?
.............................................................................................................................................................. Yes No
(b) If Yes, provide details.
(c) If No, does the Applicant agree to notify the insurance company within thirty (30) days if the
Applicant starts to render advisory services to such a client? ...............................................................
Yes No
18. Has the Applicant or any associated professional ever: Provide details to any question that is answered Yes.
(a) Had a professional license or registration denied, suspended, revoked, nonrenewed or
restricted?
Yes No
(b) Been formally reprimanded by any court, administrative or regulatory agency? Yes No
(c) Had a complaint filed with any consumer agency, state securities department, insurance
department or the ASSOLFDQW¶VEURNHU-dealer, SEC, NASD, or other regulatory agency?
Yes No
(d) Been audited by the SEC, NASD, any state securities department, or other licensing or
regulatory agency? If Yes, provide a copy of the audit letter and WKH$SSOLFDQW¶V response.
Yes No
(e) %HHQIRUPDOO\DFFXVHGRIYLRODWLQJDQ\SURIHVVLRQDODVVRFLDWLRQ¶VFRGHRIethics? Yes No
(f) Been convicted of a felony? Yes No
(g) Been involved in or is aware of any fee disputes including suits? Yes No
(h) Ever had a trading error loss in excess of $5,000? If Yes, provide details including dates,
amounts and by whom the loss was paid.
Yes No
19. During the last three (3) years has the Applicant or any affiliate been involved in, or presently
considering or contemplating any merger, acquisition, divestiture or significant change in principals?....... Yes No
If Yes, provide details.
FP3003-01 12/07 Page 4 of 5
20. Does the Applicant GLUHFWWUDGHVLQFOLHQW¶VFXVWRGLDODFcounts?..................................................................
Yes No
If Yes, complete the following:
(a) Use a written Investment Policy Statement for other than ERISA accounts? Yes No
(b) Have Limited Power of Attorney to direct tradHVLQWKHFOLHQW¶VDFFRXQW",IYes: please answer: Yes No
The Applicant uses full discretion to trade without prior consent of the client.
The Applicant uses discretion to trade within an Investment Policy Statement or written
parameters.
The Applicant declines to exercise discretion and obtains prior consent for each and
every trade.
(c) Excluding advisory fees and authorized disbursement to an account with the same registration
or the client, does the Applicant have power to withdraw/disburse funds in the account?
Yes No
(d) Custodians: Fidelity TD Ameritrade Schwab Pershing FISERV Assetmark NATC
SSG Other:
(e) Are any assets under management invested in Exchange Trade Funds? Yes No
If Yes, what percentage of:
(i) total assets under management are invested in Exchange Traded Funds? %
(ii) Exchange Traded Funds are leveraged? %
ALL APPLICANTS ± COMPLETE THE FOLLOWING:
21. Types of Accounts:
TYPES OF ACCOUNTS Number of
Accounts
Market Asset Value Largest Account
Asset Value
Discretionary ERISA Pension/Employee Benefit Plans $ $
Discretionary All Other Accounts $ $
Non-Discretionary ERISA Pension/Employee Benefit Plans $ $
Non-Discretionary All Other Accounts $ $
Investment Management Consulting Accounts (No Direct
Management)
$ $
Referral to Third Party Money Manager Accounts (No Direct
Management)
$ $
Total All Accounts $ $
22. Does the Applicant act as advisor or consultant for any Taft-Hartley, union, or governmental employee
benefit plan?................................................................................................................................................. Yes No
If Yes, attach a list of accounts and assets.
23. (a) Number of accounts lost in the last twelve (12) months:
(b) Total assets under management for accounts lost in the last twelve (12) months: $
(c) Reasons for loss of accounts:
NEW BUSINESS APPLICANTS ONLY:
24. (a) Attach a separate sheet briefly describe WKH$SSOLFDQW¶Vinvestment philosophy.
(b) Attach a separate sheet listing the types and percentages of investments used in portfolios.
25. Has any insurer declined, cancelled or nonrenewed any Investment Advisor Professional Liability Insurance or any
similar insurance on behalf of any person(s) or organization(s) proposed for this insurance?.................... Yes No
If Yes, provide details.
FP3003-01 12/07 Page 5 of 5
NOTICE TO THE APPLICANT - PLEASE READ CAREFULLY
No fact, circumstance or situation indicating the probability of a Claim or action for which coverage may be afforded by the
proposed insurance is now known by any person(s) or organization(s) proposed for this insurance other than that which is
disclosed in this application. It is agreed by all concerned that if there is knowledge of any such fact, circumstance or
situation, any Claim subsequently emanating therefrom shall be excluded from coverage under the proposed insurance.
For the purpose of this application, the undersigned authorized agent of the person(s) and organization(s) proposed for
this insurance declares that to the best of his/her knowledge and belief, after reasonable inquiry, the statements in this
application, the form ADV Parts I and II and in any attachments, are true and complete. The Cambridge Alliance, LLC or
the Company is authorized to make any inquiry in connection with this application. Signing this application does not bind
the Company to provide or the Applicant to purchase the insurance.
This application, information submitted with this application and all previous applications and material changes thereto of
which the Cambridge Alliance, LLC receives notice is on file with the Cambridge Alliance, LLC and the form ADV Parts I
and II and is considered physically attached to and part of the policy if issued. The Cambridge Alliance, LLC and the
Company will have relied upon this application, all such attachments and the form ADV Parts I and II in issuing the policy.
If the information in this application, any attachment and the ADV for Part I and II materially changes between the date this
application is signed and the effective date of the policy, the applicant will promptly notify the Cambridge Alliance, LLC,
who may modify or withdraw any outstanding quotation or agreement to bind coverage.
The undersigned declares that the person(s) and organization(s) proposed for this insurance understand that:
(i) WKHSROLF\IRUZKLFKWKLVDSSOLFDWLRQLVPDGHDSSOLHVRQO\WR³CODLPV´ILUVWPDGHGXULQJWKH³Policy PHULRG´DQGUHSRUWHG
WRWKHFRPSDQ\GXULQJWKH³Policy PHULRG´RUZLWKLQVL[W\GD\VDIWHUWKHH[SLUDWLRQGDWHRIWKH³Policy PHULRG´XQOHVV
the Extended Reporting Period is exercised. If the Extended Reporting Period is exercised, the policy shall also apply
WR ³CODLPV´ ILUVW PDGH GXULQJ WKH Extended Reporting Period and reported to the company during the Extended
Reporting Period or within sixty days after the expiration of the Extended Reporting Period;
(ii) WKHOLPLWVRIOLDELOLW\FRQWDLQHGLQWKHSROLF\VKDOOEHUHGXFHGDQGPD\EHFRPSOHWHO\H[KDXVWHGE\³Claims E[SHQVHV´
and, in such event, the CRPSDQ\ZLOOQRWEHOLDEOHIRU³Claims E[SHQVHV´RUWKHDPRXQWRIDQ\MXGJPHQWRUVHWWOHPHQW
to the extent that such costs exceed the limits of liability in the policy; and
(iii) ³Claims E[SHQVHV´VKDOOEHDSSOLHGDJDLQVWWKH³DHGXFWLEOH´
WARRANTY
I/We warrant to the Company, that I/We understand and accept the notice stated above and that the information contained
herein is true and that it shall be the basis of the policy and deemed incorporated therein, should the Company evidence
its acceptance of this application by issuance of a policy. I/We authorize the release of claim information from any prior
insurer to The Cambridge Alliance, LLC or the Company, P.O. Box 64998, Burlington, Vermont 05406.
Note: This application is signed by undersigned authorized agent of the Applicant(s) on behalf of the Applicant(s) and its,
owners, partners, directors, officers and employees.
Must be signed by the owner, principal, partner, executive officer or equivalent (within 60 days of the proposed effective date).
NOTICE TO APPLICANT: Any person who knowingly files an application for insurance or statement of claim containing
any 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 also punishable by civil penalties in certain jurisdictions.
Print Name:
Title:
Signature: Date:
Signing this application does not bind the Company or the Applicant or the underwriter to complete the insurance.
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APPLICATION FOR FINANCIAL ADVISORS PROFESSIONAL LIABILITY INSURANCE NEW (RT Specialty)

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Completed 13 December 2020

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