Fillable Fiduciary Employee Benefits Application (CSRisks)

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Fiduciary Employee Benefits Application (CSRisks)

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Fiduciary & Employee Benets Liability Application
*To be able to save this form after the elds are lled in, you will need to have Adobe Reader 9 or later. If you do not have
version 9 or later, please download the free tool at: http://get.adobe.com/reader/.
FDIC #: ___________________________
DATE: ___________________________
THE LIABILITY POLICY THAT MAY BE ISSUED BASED UPON THIS APPLICATION PROVIDES CLAIMS MADE
COVERAGE WRITTEN ON A NO DUTY TO DEFEND BASIS. DEFENSE COSTS ARE INCLUDED WITHIN THE LIMIT OF
LIABILITY AND REDUCE THE LIMIT OF LIABILITY AVAILABLE TO PAY SETTLEMENTS AND JUDGMENTS. PLEASE
READ THE POLICY CAREFULLY.
Applicant (Parent Company): __________________________________________________________________ FDIC #: ________________
Address: __________________________________________ City: _________________ State: ____________ Zip Code: ______________
P.O. Box : _________________________________________ City: _________________ State: ____________ Zip Code: ______________
Telephone: ________________________________________ Website: ________________________________
Representative authorized to receive notices on behalf of the applicant and all subsidiaries:
Name: ___________________________________________ Title: ___________________________ Email: __________________________
For purposes of this Application for coverage, “Applicant” means the Parent Company and any Subsidiary listed below,
including any limited liability companies and joint ventures for which coverage is desired.
1. Applicant is a:
Commercial Bank
Savings Bank
Savings & Loan/Thrift
Bank Holding Company
Multi-bank Holding Company
Other (specify):
2. Stock is:
Privately Held
Publicly Traded
Not Applicable (Mutual Association)
3. If Parent Company or any Subsidiary is a Mutual Association, are there any plans to convert to
stock ownership? If yes, attach details.
Yes
No
4. Total shares outstanding: __________________ Ticker Symbol (if applicable): __________________
5. Number of shareholders: __________________ Number of shares owned directly or benecially by D&Os: __________________
6. Does any shareholder own 5% or more of common stock (including debentures convertible to common stock,
which if exercised, would result in a controlling interest)?
If yes, attach details including names and percentages owned.
Yes
No
7. During the past 5 years, has the Applicant been involved in any actual or proposed merger, acquisition or
stock divestment? If yes, attach details.
Yes
No
8. During the past 5 years, has there been any changes in controlling ownership of 10% or more of the
Applicant’s stock, or are there any negotiations pending to sell 10% or more of the Applicant’s stock?
If yes, attach details.
Yes
No
9. Has the Applicant conducted a private or public securities offering during the past 12 months or is such an
offering contemplated within the next 12 months? If yes, attach details including the Prospectus or Private
Placement Memorandum.
Yes
No
10. Number of:
Full & Part-time Employees: __________________ Branch Locations (including Main Ofce): __________________
Off-Premise Automated Teller Machines (ATMs): __________________ Foreign Branch Locations: __________________
General Information
Current Coverage (New Applicants only)
Security National Insurance Company Wesco Insurance Company
AmTrust Insurance Company of Kansas
(all states except: AZ, CT, DE, FL, LA and NJ) (applies to: AZ, CT, DE, FL and NJ) (LA only)
Type of coverage: Carrier Limit Indicate if Separate Limit Retention Premium Expiration
Fiduciary Liability: ___________ $ ___________
$ ____________ $ ____________ ____________
Corporate Structure
APPL-BANC-FEBL-01 0413 Page 1 of 5
APPL-BANC-FEBL-01 0413 Page 2 of 5
1. During the past 5 years:
a) have there been any changes in Chairman of the Board, President, Chief Financial Ofcer,
Chief Operations Ofcer or Chief Lending Ofcer?
Yes
No
b) were there any loans to Directors or Ofcers or any of their afliates criticized, classied or 90 days
past due?
Yes
No
c) has any Director or Ofcer been charged with or convicted of any criminal act or been the subject of
a criminal investigation?
Yes
No
If any answer is yes, attach details.
2. External audit is:
Full-scope
Directors-scope
Not Performed
3. The external audit is performed:
Annually
Every other year
Other
Not Applicable
4. Were all weaknesses identied in the most recent Management letter addressed by the
Board of Directors? Not Applicable Yes No
5. Does the Applicant have a continuous internal audit by an internal auditor who reports directly to the
Board of Directors? Yes No
6. For each depository institution applying for coverage, please provide the following:
a) Last Regulatory Examination Date: __________________ Regulatory Agency: __________________
b) Current level of internally classied assets: Substandard: $ ___________ Doubtful: $ __________ Loss: $ ___________
c) Have all criticisms or comments cited as of the most recent regulatory examination, internal audit
and external audit been addressed by the Board of Directors? Yes No
d) During the past 3 years, has the Applicant or any Subsidiary been or, to the best of your knowledge
do you anticipate that the Applicant or any Subsidiary will be placed under a Cease and Desist Order,
Formal Written Agreement, Consent Order, Supervisory Agreement, Memorandum of Understanding
or similar regulatory agreement? Yes No
e) Were adversely classied assets (sum of substandard, doubtful and loss) from the most recent
regulatory exam in excess of 40% of capital? Yes No
f) During the past 3 years, has the Applicant been alerted to any:
i. Concentration of credit that warranted a reduction or correction? Yes No
ii. Legal lending limit violations? Yes No
iii. Violations of law cited as a result of a regulatory examination? Yes No
If any answers to question 6(a) to 6(f) are yes, attach details, including copy of regulatory order(s)
and most recent response.
Management / Oversight
Complete the “Professional Services Supplemental Application”, if coverage is desired for any
business activity listed below.
1. Professional Services:
Indicate if the Applicant offers or plans to offer any of the following (check all that apply): Offers or Plans to Offer
a) Data Processing Services (for others)
b) Insurance Agent/Agency Services
c) Investment Advisor/Financial Planning (outside Trust Department)
d) Real Estate Services (appraisal services, property management, title abstracter services
and title agent services)
11. List all subsidiaries (including limited liability companies and joint ventures) here or by attachment.
Subsidiary Parent Date established % Owned Nature of Business
%
%
%
It is understood and agreed that coverage will not be provided for any Subsidiary, limited liability company or joint
venture unless listed above and expressly agreed to by the Insurer.
Scope of Business Activities
APPL-BANC-FEBL-01 0413 Page 3 of 5
Fiduciary & Employee Benets Liability
Complete this section only if coverage is desired for Applicant’s retirement and welfare benet plans.
1. Professional Services (continued):
Indicate if the Applicant offers or plans to offer any of the following (check all that apply): Offers or Plans to Offer
e) Security Broker/Dealer Services (purchase or sale of securities by a registered broker/dealer
or discount brokerage services)
f) Trust Department Services
g) International Banking (including nancing, import/export letters of credit, etc.)
h) Real Estate Investment Trust (REIT)
It is understood and agreed that coverage will not be provided for any of the above Professional Services unless
indicated above and expressly agreed to by the Insurer.
2. Does the Applicant carry any errors and omissions insurance policies, for any of the above
listed services? If yes, attach a copy of policy.
Yes
No
3. Lending Activities:
a) Indicate the dollar amount of loan participations accepted from other originating
nancial institutions.
Not Applicable $ ___________
b) If the Applicant funds construction loans without rm takeout commitments,
indicate the current dollar amount of portfolio.
Not Applicable $ ___________
c) Indicate the dollar amount of loans made outside the Applicant’s dened
trade territory.
Not Applicable $ ___________
d) If the Applicant services loans for other originating nancial institutions, indicate
the current dollar amount of the portfolio.
Not Applicable $ ___________
e) If the Applicant’s lending activities encompass dealer oor planning, indicate
dollar amount of portfolio.
Not Applicable $ ___________
f) If the Applicant sells loans with recourse, indicate current dollar amount of portfolio.
Not Applicable $ ___________
g) Does the Applicant operate a mortgage banking operation? If yes, attach details.
Yes
No
h) Does the Applicant engage in sub-prime lending, “pay day” lending or any other
lending activities that are considered to be a higher risk for class-action litigation?
Yes
No
If yes, attach details.
1. Complete the following for all Plans:
Plan Name Type of Plan*
(see choices below)
Most Recent
Asset Value
Year
Established
Number of
Participants
$
$
$
* Plan Types: (a) ESOP; (b) 401k Plan; (c) Prot Sharing Plan and Dened Benet (Pension) Plan; or (d) other
It is understood and agreed that coverage will not be provided for any Plan unless listed above and expressly agreed to
by the Insurer.
2. Does any Plan listed above have a funding deciency?
Yes
No
3. Is any Plan currently under examination or is any issue related to a Plan currently pending before the
Internal Revenue Service, Department of Labor, the Pension Benet Guaranty Corporation or any court?
Yes
No
4. If the Applicant has an Employee Stock Ownership Plan (ESOP), indicate the percentage of company
stock owned by the ESOP. % ___________
New Applicants:
It is understood and agreed that any claim or potential claim arising from any prior unauthorized access or systems intrusion shall be
excluded from coverage. It is further understood and agreed that if the Applicant has knowledge of any fact, circumstance or situation
which could reasonably be expected to give rise to any claim for the coverage herein applied for, any such claim subsequently arising
therefrom shall also be excluded from coverage.
APPL-BANC-FEBL-01 0413 Page 4 of 5
Fraud Warning
Prior/Pending Litigation & Claims History (All Applicants)
1. Is the Applicant or any Subsidiary a defendant in any lawsuit which, if the allegations are proven,
could materially affect the nancial condition of the company?
Yes
No
2. New Applicants only:
a) Have there been during the past 3 years, or is there now pending, any lawsuits, administrative
charges or proceedings, written or oral demands for monetary damages or non-monetary relief,
civil or criminal proceedings, formal civil administrative or regulatory proceedings, or arbitration
proceeding, involving the Applicant, any Subsidiary or any past or present director, ofcer employee
proposed for this insurance?
Yes
No
b) Does the Applicant, any Subsidiary, any director or ofcer, or any other person proposed for this
insurance have knowledge of any fact, circumstance or situation related to any coverage herein
applied for which could reasonably be expected to give rise a future claim?
Yes
No
If Question 1 or Question 2 is yes, attach full details.
New Applicants:
It is understood and agreed that any claim arising from any prior or pending litigation or written or oral demand shall be excluded from
coverage. It is further understood and agreed that if any fact, circumstance or situation which could reasonably be expected to give
rise to a future claim exists, any claim or action subsequently arising therefrom shall also be excluded from coverage.
Renewal Applicants:
It is understood and agreed that if the undersigned or any insured has knowledge of any fact, circumstance or situation which could
reasonably be expected to give rise to a future claim, then any increased limit of liability or coverage enhancement shall not apply to
such fact, circumstance, or situation. In addition, any increased limit of liability or coverage enhancement shall not apply to any claim,
fact, circumstance or situation for which the Insurer has already received notice.
Any person who knowingly and with intent to defraud any insurance company or another person les 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 may be a crime and may subject the
person to criminal penalties.
ALABAMA, ARKANSAS, LOUISIANA, NEW JERSEY, NEW MEXICO, RHODE ISLAND, VIRGINIA and WEST VIRGINIA: Any person who knowingly presents a false or
fraudulent claim for payment of a loss or benet or knowingly presents false information in an Application for insurance is guilty of a crime. In Alabama, Arkansas, Louisiana, Rhode
Island and West Virginia that person may be subject to nes, imprisonment or both. In New Mexico, that person may be subject to civil nes and criminal penalties. In Virginia, penalties
may include imprisonment, nes and denial of insurance benets.
COLORADO: 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, nes, 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 a
settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
DISTRICT OF COLUMBIA, KENTUCKY and PENNSYLVANIA: Any person who knowingly and with intent to defraud any insurance company or other person les an Application
for insurance or statement of claim containing 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. In District of Columbia, penalties include imprisonment and/or nes. In addition, the Insurer may deny insurance benets if the Applicant
provides false information materially related to a claim. In Pennsylvania, the person may also be subject to criminal and civil penalties.
FLORIDA and OKLAHOMA: Any person who knowingly and with intent to injure, defraud or deceive the Insurer, les a statement of claim or an Application containing any false,
incomplete or misleading information is guilty of a felony. In Florida it is a felony to the third degree.
KANSAS: 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 benet pursuant to an insurance policy for personal or commercial insurance which such person knows to contain
materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto is considered a crime.
MAINE: 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, nes or denial of insurance benets.
MARYLAND: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benet or knowingly or willfully presents false information in an
Application for insurance is guilty of a crime and may be subject to nes and connement in prison.
OHIO: Any person who, with intent to defraud or knowing that he is facilitating a fraud against the Insurer, submits an Application or les a claim containing a false or deceptive
statement is guilty of insurance fraud.
OREGON: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benet or knowingly presents false information in an application for insurance may be
guilty of a crime and may be subject to nes and connement in prison.
TENNESSEE and WASHINGTON: 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, nes and/or denial of insurance benets.
800 Superior Avenue E., 21st Floor • Cleveland, OH 44114 • Phone: 866.327.6904 • Fax: 216.328.6251 • www.amtrust.com
Submit applications to: banksubmissions@amtrustgroup.com
APPL-BANC-FEBL-01 0413 Page 5 of 5
MKT0810 4/15
Representation Statement
The undersigned declare that, to the best of their knowledge and belief, the statements in this Application, any prior Applications, any additional material submitted, and any publicly
available information published or led by or with a recognized source, agency or institution regarding business information for the Applicant for the 3 years prior to the Bond/
Policy’s inception [hereinafter called “Application”] are true, accurate and complete, and that reasonable efforts have been made to obtain sufcient information from each and every
individual or entity proposed for this insurance. It is further agreed by the Applicant that the statements in this Application are their representations, they are material and that the
Bond/Policy is issued in reliance upon the truth of such representations.
The signing of this Application does not bind the undersigned to purchase the insurance and accepting this Application does not bind the Insurer to complete the insurance or
to issue any particular Bond/Policy. If a Bond/Policy is issued, it is understood and agreed that the Insurer relied upon this Application in issuing each such Bond/Policy and any
Endorsements thereto. The undersigned further agrees that if the statements in this Application change before the effective date of any proposed Bond/Policy, which would render
this Application inaccurate or incomplete, notice of such change will be reported in writing to the Insurer immediately.
Please provide the following information with your submission:
• Current Declarations Page from the Applicant’s Financial Institution Bond, D&O Policy, Bankers Professional Liability Policy,
Trust Errors & Omissions Policy, Employment Practices Liability Policy and/or Kidnap & Ransom Policy, if such bond/policies
are not currently written by AmTrust North America.
• Most recent Annual Report or audited nancial statements. If not applicable, attach a copy of the most recent Directors’
Examination Report.
• Management Letter and Applicant’s responses to any recommendations made therein.
• If applicable, most recent Form 10-K, 10-Q and any other Registration Statement led with the SEC within the past 12 months.
Submit Application to:
banksubmissions@amtrustgroup.com
AmTrust North America
Attention: Financial Institution Division
800 Superior Avenue E., 21st Floor • Cleveland, OH, 44114
Phone: 866.327.6904 • Fax: 216.328.6251
www.amtrustnorthamerica/nancial-institutions.com
Chief Executive Ofcer, President or Chairman of the Board:
Print Name: _________________________________________________ Signature: ____________________________________________
Title: _______________________________________________________ Date: ________________________________________________
Chief Financial Ofcer or Equivalent Ofcer:
Print Name: _________________________________________________ Signature: ____________________________________________
Title: _______________________________________________________ Date: ________________________________________________
A BOND/POLICY CANNOT BE ISSUED UNLESS THE APPLICATION IS SIGNED AND DATED BY TWO INDIVIDUALS
Agent Name: ________________________________________________ License Number: _______________________________________
Agent Signature: _____________________________________________
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Fiduciary Employee Benefits Application (CSRisks)

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Completed 19 July 2020

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