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BOND SUPPLEMENTAL APPLICATION (Risk Placement Services, Inc.)

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MALP 0003 07 13 Page 1 of 3
BOND SUPPLEMENTAL APPLICATION
APPLICANT’S INSTRUCTIONS:
This form is to be completed by each Applicant that has performed any Bond-related work of any kind during the past
five (5) years. The time period contemplated by each question is the five (5) year period prior to the date of completion
of this supplement. Please answer all questions completely. Attach a separate sheet if necessary.
APPLICANT NAME:
1. LA
WYER BOND EXPERIENCE – Provide the following information for all lawyers engaged in Bond or Bond-related
practice:
LAWYER’S NAME
NUMBER OF BOND
ISSUANCES HANDLED IN
CAREER
NUMBER OF BILLABLE
HOURS FOR THE PAST
YEAR IN BOND WORK
2. a. LAWYER BOND ACTIVITIES – Please check whether or not you have performed the activities shown below,
relative to any Bonds you have worked on.
i. Preparation or review of legal documents.
Yes No
ii. Assuring compliance with Rule 15c 2-12.
Yes No
iii. Opined on legal validity/authority for the Bond transaction.
Yes No
iv. Opined on tax status of a Bond issuance.
Yes No
v. Opined on economic or business viability of a project.
Yes No
vi. Prepared the official statement of other disclosure documents.
Yes No
b. ADDITIONAL BOND ACTIVITIES – Please check whether or not you have ever performed any of the activities
shown below on any of the Bonds which you have worked on. For any Yes answer, please provide complete
details by attachment.
i. Locating prospective Bond purchasers.
Yes No
ii. Marketing, promotion, or sale of Bonds.
Yes No
iii. Direct dissemination of offering related materials to prospective Bond purchasers.
Yes No
iv. Business related due diligence on any Bond project.
Yes No
v. Served as Bond holder trustee.
Yes No
vi. Involved in any way with any kind of Bond derivative type product.
Yes No
3. MULTIPLE BOND CLIENT REPRESENTATIONS – For all Bond issuances in the past five (5) years, indicate below
how many times you have represented two (2) or more parties to the same bond issuance or transaction.
a. Issuer and Underwriter.
b. Issuer and one or more Bond Purchaser(s).
c. Underwriter and one or more Bond Purchaser(s).
d. Issuer and Corporation or Developer in Industrial Revenue Bond or Conduit Bond setting.
e. Other (describe):
Broker Name
Broker Street
Broker City, State, Zip
Deerfield Insurance Company
Evanston Insurance Company
Essex Insurance Company
Markel American Insurance Company
Markel Insurance Company
Associated International Insurance Company
MALP 0003 07 13 Page 2 of 3
4. KEY EVENTS – Please check whether or not, to the best of your knowledge, any of the following events or situations
have occurred relative to any Bond offering you have worked on in the past five (5) years. For any Yes answers,
provide complete details by attachment.
a. Default or delinquency in payment of any Bond principal or interest.
Yes No
b. Default proceeding instituted.
Yes No
c. Technical default relative to any Bond covenant.
Yes No
d. Bond project halted prior to completion, or went into bankruptcy or receivership.
Yes No
e. Notice of IRS adverse tax stance or ruling.
Yes No
f. Investigation by any federal or state regulatory agency.
Yes No
g. Litigation of any kind.
Yes No
5. SCHEDULE OF BOND ISSUANCES – Complete the following relative to all Bond issuances that you have worked on in
the past five (5) years. If you have more than three (3) offerings, please provide information on all of those by attachment.
Offering #1 Offering #2
Offering #3
Date of Offering
Name of Issuer
Issuer City, State
Public or Private Offering
Total Dollar Size of Offering
Bond Type (see key below)
Project Type if Revenue, Indus.
Devel. or Conduit Bond
First Time Issuer – Yes/No
Start Up Project – Yes/No
Insured Bond – Yes/No
Current Moody’s or S&P Rating
Bond Type: G – General Obligation R – Revenue I – Industrial Development C -Conduit
I understand the information submitted herein becomes a part of my Professional Liability Insurance Application and is
subject to the same representations and conditions.
Notice 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 in
the third degree.
Notice to New York Applicants: 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 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.
Signature of Owner, Officer or Partner Print or Type Name and Title Date (month-day-year)
Producers Must Complete:
Produced By (Insurance Agent or Broker):
Producer Name: Producer Signature:
Producer License No.: Date:
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MALP 0003 07 13 Page 3 of 3
Notice to Alabama Applicants; Any person who knowingly presents a false or fraudulent claim for payment of a loss or
benefit or who knowingly 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.
Notice to Arkansas, District Of Columbia, New Mexico, Rhode Island And 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.
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 policyholder 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 Kansas Applicants: It is unlawful to commit a “fraudulent insurance act” which means an act committed by
any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or
belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as
part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial
insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance
which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the
purpose of misleading, any information concerning any fact material thereto.
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 Maine, Tennessee, Virginia and 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 may include
imprisonment, fines, or denial of insurance benefits.
Notice to Maryland Applicants: Any person who knowingly or willfully presents a false or fraudulent claim for payment of
a loss or benefit or who knowingly or willfully 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 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 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.
Notice 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.
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 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.
Notice to Vermont Applicants: Any person who knowingly presents a false statement in an application for insurance may
be guilty of a criminal offense and subject to penalties under state law.
Notice to Applicants of all other 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 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.
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BOND SUPPLEMENTAL APPLICATION (Risk Placement Services, Inc.)

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Completed 23 November 2020

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