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ExecPrExecPro o ExecPrExecPr oo Proposal FormProposal Form (Access E&S Insurance Services)

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Proposal Form
Proposal FormProposal Form
Proposal Form
for
Fiduciary Liability Insurance
FIDUCIARY PROPOSAL FORM
FIDUCIARY PROPOSAL FORMFIDUCIARY PROPOSAL FORM
FIDUCIARY PROPOSAL FORM
Name of Company:
Street Address:
City, State, Zip:
Internet Website Address: ______________________________________________________________________________________
Please list the officer designated as agent of the Company and of all proposed Insureds to receive any and all notices from the Insurer
or its authorized representatives concerning this insurance:
Name __________________________________________ Title ____________________________________________________
EMPLOYEE INFORMATION
1. Number of: Full-time employees____________; Part-time employees_____________.
2. Does the Company make use of independent contractors or non-employee labor? Yes No
If “Yes”, provide the number of such workers used in the last 12 months____________________________________________
EMPLOYEE BENEFIT PLAN INFORMATION
3. Provide the name, type of plan, total asset value and /or the total annual contributions and number of participants (active and
retired or separated) for all Employee Benefit Plans of the Company for which coverage is sought including deferred
compensation plans whether intended to be covered by ERISA or not. (Use form attached to this Proposal Form).
4. Does any plan or trust hold any “employer securities” as defined by ERISA? Yes No
If “Yes”:
(a) List each plan and the percentage of the Company’s securities held by each such plan or trust? _______________________
______________________________________________________________________________________________________
(b) Is the trustee of each such plan independent of the Company? Yes No
(c) If a private company, how often and by what method is the stock valued? ________________________________________
___________________________________________________________________________________________________
(d) Who has the voting rights for the shares of stock in the plan or trust ____________________________________________
___________________________________________________________________________________________________
5. Does any plan employ the services of:
(a) An investment management or consulting firm? Yes No
(b) A certified public accounting firm? Yes No
(c) An outside law firm? Yes No
(d) An actuarial firm? Yes No
D3200 1
If “Yes”, to any of (a) – (d), provide the name of each firm used by each plan: _______________________________________
______________________________________________________________________________________________________
If “Yes”, to (d), provide:
date of latest actuarial assessment:________________________________________________________________
did the assessment contain qualifications? Yes No
If “Yes”, attach a copy of the assessment.
were all the criticisms in the assessment corrected? Yes No
If “No”, attach an explanation.
6. If any plan does not employ the services of an independent investment manager, who is responsible for the investment
decisions of that plan?
______________________________________________________________________________________________________
7. Are any plan benefits secured by insurance? Yes No
If “Yes”, describe the types of insurance and the carrier(s) providing such insurance: __________________________________
______________________________________________________________________________________________________
PLAN CHANGES
8. In the past three years:
(a) Has any plan been consolidated or merged into any plan for which coverage is sought? Yes No
(b) Has there been any amendment to any plan that has resulted in a change or reduction in benefits to Yes No
participants including the change to a cash-balance plan?
If “Yes”, provide details.
(c) Has the Company or any Subsidiary engaged in any transaction which caused any other entity to become Yes No
the sponsoring employer of any employment Benefit plan, or which caused employees of the Company or
any Subsidiary to become covered by a different Employee Benefit Plan, or which resulted in the termination
of any Employee Benefit Plan?
If “Yes”, provide details including the date of such transaction, the date of any asset distribution or transfer, whether benefits
were secured through the purchase of annuities, guaranteed investment contracts or other similar investments, and, if so, the
name of the investment sponsor, and whether any plan assets reverted to any party other than plan participants.
9. Does the Company or any Subsidiary expect any of the events set forth in question 8. above to occur in the Yes No
next 12 months?
If “Yes”, provide details.
COMPLIANCE
10. Do the persons responsible for plan administration meet regularly to conduct plan business, review Yes No
performance of outside service providers and review claims under the plan? How often?_________________
11. Does each plan subject to the Employee Retirement Income Security Act of 1974 (ERISA), comply Yes No
with the requirements of ERISA relating to eligibility, participation, vesting, funding and all other matters?
If “No”, provide details.
12. At any time during the last five years has any plan had a funding deficiency? Yes No
D3200 2
13. At this time are there any delinquent contributions? Yes No
14. In the past 5 years, has there been any “reportable event” as defined in ERISA with respect to any plan? Yes No
15. Are there any transactions involving plan assets involving anyone known to be a party-in-interest? Yes No
16. Has any plan(s) invested in more than 10% of any corporation or partnership? Yes No
If “Yes” to any question 12. – 16., provide details.
17. Has the Company in the past, or does the Company anticipate in the next 12 months, allowing for Yes No
enhanced benefits to employees electing early retirement if elected during a specified time period?
If “Yes”, provide details including whether such plans have been disclosed to all employees.
PRIOR ACTIVITIES
18. Have there been during the last five years, or are there now pending, any claims or suits brought against the
plan(s), Sponsor Organization or its Subsidiaries, or any person proposed for this insurance which would have
been covered by insurance similar to that applied for? Yes No
If “Yes”, provide details in an attachment to this Proposal Form.
IT IS AGREED THAT ANY CLAIM ARISING FROM ANY PRIOR OR PENDING PROCEEDING IS
EXCLUDED FROM THE PROPOSED COVERAGE.
19. Is the undersigned or any other person(s) proposed for this insurance aware of any fact, circumstance or
situation involving the Sponsor Organization, its Subsidiary(ies), the plan(s) or any other person proposed
for this insurance, which he or she has reason to believe might result in any future claim which would fall
within the scope of the proposed insurance? Yes No
If “Yes”, provide details in an attachment to this Proposal Form.
IT IS AGREED THAT IF KNOWLEDGE OF ANY SUCH FACT, CIRCUMSTANCE OR SITUATION EXISTS,
ANY CLAIM SUBSEQUENTLY ARISING THEREFROM SHALL BE EXCLUDED FROM COVERAGE.
PRIOR INSURANCE
20. Previous Employee Pension/Welfare Benefit Plan Fiduciary Liability Insurance (answer each item):
(a) Carrier______________________________________________________________________________________________
(b) Limit_____________Deductible___________ Policy Period________________________ Premium__________________
(c) Has any Claim been made or has notice been given to any Insurer? Yes No
(d) Has any carrier refused, cancelled or non-renewed coverage? Yes No
(e) If cancelled or non-renewed, has the discovery option been exercised? Yes No
If “Yes” to any of the above, please provide details in an attachment to this Proposal Form.
NOTICE 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.
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
D3200 3
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 a settlement or award payable from 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 reported by the applicant.
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 of the
third degree.
Also provide: Agent name ______________________________________________ License number ____________________
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 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.
NOTICE TO NEW MEXICO 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 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 YORK 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
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 ($5,000.00) and the stated value for each such violation.
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 PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to injure or defraud any insurer files an
application or claim containing any false, incomplete or misleading information shall, upon conviction, be subject to
imprisonment for up to seven years and payment of a fine of up to $15,000.
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 undersigned Plan Administrator(s) and Officer of the Sponsor Organization on behalf of the Sponsor Organization, Plan(s)
proposed and any other person(s) proposed for this insurance declare that to the best of their knowledge the statements set forth herein
are true and correct and that reasonable efforts have been made to obtain sufficient information to facilitate the proper and accurate
completion of this Proposal Form. The undersigned further agree that if any significant adverse change in the condition of the
applicant is discovered between the date of this Proposal Form and the effective date of the Policy, which would render this Proposal
Form inaccurate or incomplete, notice of such change will be reported in writing to the Insurer immediately. The signing of this
Proposal Form does not bind the undersigned to purchase the insurance.
It is agreed by the Company and the persons proposed for this insurance that the particulars and statements contained in this Proposal Form
and any information provided herewith (which shall be on file with the Insurer and be deemed attached hereto as if physically attached
hereto) are the basis of this Policy and are to be considered as incorporated in and constituting a part of this Policy. It is further understood
and agreed by the Company and the persons proposed for this insurance that the statements in this Proposal Form or any information
provided herewith are their representations, they are material and this Policy is issued in reliance upon the truth of such representations;
provided, however, that except for material facts or circumstances known to the persons who subscribed this Proposal Form, any
misstatement or omission in this Proposal Form or information provided herewith in respect of a specific Wrongful Act by a particular person
proposed for this insurance or his or her cognizance of any matter which he or she has reason to believe might afford grounds for a future
Claim against him or her shall not be imputed to any other person proposed for this insurance for purposes of determining the validity of this
Policy as to such other person proposed for this insurance.
D3200 4
This Proposal Form must be signed by the Chairman of the Board, President, Chief Executive Officer, Chief Operating
Officer, or Chief Financial Officer of the Company and by a Plan Administrator.
________________________________________________ _________________________________________ ______________
Signature (Senior Officer) Title Date
________________________________________________ _________________________________________ _______________
Signature (Plan Administrator) Title Date
Please submit one copy of each of the following documents:
(a) The most recently filed Form 5500 and schedules for all Plans listed in the response to Question 1;
(b) The most recent audited financial statements for each Plan;
(c) The most recent annual report of the Sponsor Company;
(d) If applicable, any required attachments in response to questions on this Proposal Form.
NOTE: The above materials are considered part of the Proposal Form.
This Proposal including any material submitted herewith shall be treated in strictest confidence.
Please submit this Proposal Form including appropriate documentation to:
Great American Insurance Companies, Executive Liability Division, P.O. Box 66943, Chicago, IL 60666
D3200 5
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ATTACHMENT TO PROPOSAL FORM FOR FIDUCIARY LIABILITY INSURANCE
Question 3.
PLAN NAME TYPE $ ASSETS $CONTRIBUTIONS # PARTICIPANTS
Active Retired or Separated
1. _____________________________________________________________________________________________________________________________________________
2. _____________________________________________________________________________________________________________________________________________
3. _____________________________________________________________________________________________________________________________________________
4. _____________________________________________________________________________________________________________________________________________
5. _____________________________________________________________________________________________________________________________________________
6. _____________________________________________________________________________________________________________________________________________
7. _____________________________________________________________________________________________________________________________________________
8. _____________________________________________________________________________________________________________________________________________
9. _____________________________________________________________________________________________________________________________________________
10. _____________________________________________________________________________________________________________________________________________
TYPE OF PLAN: WB = welfare benefit DC = defined contribution DB = defined benefit O = other
D3200 6
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ExecPrExecPro o ExecPrExecPr oo Proposal FormProposal Form (Access E&S Insurance Services)

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Completed 8 January 2021

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