Fillable Actuaries Supplemental Application Submit With Miscellaneous Professional Application

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Actuaries Supplemental Application Submit With Miscellaneous Professional Application

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Page 1 of 4
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
ACTUARIES SUPPLEMENTAL APPLICATION
(Should be submitted along with the Miscellaneous Errors and Omissions Application)
1. Total Number of Actuaries or Other Professionals:
2. Type of Clients:
% Insurance Companies
% Local Government
% Unions
% Consulting*
% Federal Government
% Other (describe):
% State Government
100% TOTAL (Must total 100%)
*If consulting clients, provide a narrative description of the work performed and copy of standard contract.
3. If any “insurance company” work, please complete this question.
If clients include insurance companies, how many carriers have been downgraded or gone into receivership
or bankruptcy during the past 24 months?
4. What proportion of actuarial or consulting gross revenues are from the following areas:
% Property and Casualty
% Pension
% Life
Other (describe):
%
% Health
5. Does applicant issue any signed actuarial opinions/reserve certifications? Yes No
If so, how many actuarial opinions has the firm performed in the past 12 months?
How many do you expect to perform in the next 12 months?
6. Does the actuary consult on mergers and acquisitions? Yes No
APPLICANT’S INFORMATION
Page 2 of 4
If answer is yes, please complete the following:
a) How many such consultations (even if the merger or acquisition was not completed) in the past 24
months?
b) How many such consultations are projected in the next 12 months?
c) Please complete the following exhibit for all merger and acquisition work for the past 24 months:
Date Work
Performed
Industry Describe Work
Performed
Capitalization or
Revenue Size of
Company
Publicly or
Privately Held
Gross Revenue
derived by your firm
for Work Performed
7. How many actuaries with the firm hold the following designations?
FCAS FSA
ACAS ASA
FSPA MSPA
8. After inquiry with each person as appropriate, in the last five (5) years, has any professional liability
claim or suit ever been made against the Firm or any predecessor firm or any current or former member of
the Firm or predecessor firm? Yes
No
If “Yes,” how many? Please complete a separate Supplemental Claim Form for
each claim or suit and include a currently valued loss run for each claim.
9. After inquiry with each person as appropriate, do you, or any of your partners, officers,
directors, or employees know of any circumstances, acts, errors, omissions, or any allegations or contentions
of any incident that could result in a claim? Yes
No
If “Yes,” how many? If “Yes,” please complete a separate Supplemental Claim Form
for each potential claim and provide as much details as possible.
Page 3 of 4
10. After inquiry with each person as appropriate, has any current or former actuary or other professional for
whom coverage is sought ever been sanctioned by any administrative agency or regulatory body, including
the Actuarial Board for Counseling and Discipline, or been subject of a disciplinary complaint made to any of
the aforementioned entities? Yes
No
If “Yes,” please provide a copy of the complaint, your response, and a copy of their decision.
FRAUD WARNING
NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS,
MARYLAND, MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH
CAROLINA, NORTH DAKOTA, OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA,
WISCONSIN, AND WYOMING APPLICANTS: In some states, any person who knowingly, and with intent to defraud any insurance company or other
person, files an application for insurance or statement of claim containing any materially false information, or, for the purpose of misleading, conceals
information concerning any fact material thereto, may commit a fraudulent insurance act which is a crime in many states.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company 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 policy holder or
claimant for the purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance
proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
NOTICE 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.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of
claim containing any false, incomplete or misleading information is guilty of a felony of the third degree.
NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or
benefit is a crime punishable by fines or imprisonment, or both.
NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance 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.
NOTICE 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.
NOTICE 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 denial of insurance benefits.
NOTICE 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.
NOTICE 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.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an insurance company or other person files an application 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 $5,000 and the stated value
of the claim for each such violation.
Page 4 of 4
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she 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.
NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes a any claim
for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company, or other person, files an
application for insurance or statement of a 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 the person to criminal and civil penalties.
NOTICE 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.
NOTICE 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.
The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant warrants that the
above statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or
omit any material facts.
The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise prior to the effective
date of any policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may be modified or withdrawn
based upon such changes at our sole discretion.
Completion of this form does not bind coverage. Applicant’s acceptance of the company’s quotation is required prior to binding coverage and policy
issuance. All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by reference into
this application and made a part of this application.
Applicant:
Title:
(Must be signed by a Principal, Partner, or Officer of the Firm)
Applicant’s Signature: Date:
Agent/Broker:
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Actuaries Supplemental Application Submit With Miscellaneous Professional Application

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Completed 2 July 2020

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