Fillable Fiduciary Liability Application - Fiduciary_Liability_Application

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Fiduciary Liability Application - Fiduciary_Liability_Application

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Page1of16

KinsaleInsuranceCompany

P.O.Box17008

Richmond,VA23226

(804)289‐1300

www.kinsaleins.com



FIDICUARYLIABILITYAPPLICATION



1. Legalnameofthebusinesswhichistheprimaryapplicantandwillbethefirstnamedinsuredlistedonthepolicy:



2. Pleaselistallotherbusiness/dbanames,includingsubsidiariesforwhichyouareseekingcoverageunderthispolicy:



3. Applicantis: Individual Partnership Corporation



Non‐Profit PrivatelyHeld PubliclyTraded

4. Pleaselistanynamesofotherentitiesthatyouownormanageorthatyoudobusinessunder(suchentitiesarenot

requestingcoverageunderthispolicy):



5. Subsidiaries–Pleaseattachthefollowinginformationonallsubsidiaries(includingsubsidiariesofsubsidiaries):

a. Nameandaddress

b. Percentageofownership

c. Natureofbusiness

d. NameofParentCompany

6. Primarylocationaddress:

7. Countyofprimarylocation:Datebusinessoriginallyestablished:    

8. Totalnumberofbranches:  Listalladdressesforadditionalbranches:



9. Whatisyourweb‐siteaddress?www.

10. Whatisyourphonenumber?

11. Hasthenameorownershipoftheentitychangedorhasanyotherbusinessbeenpurchased, Yes No 

mergedorconsolidatedwiththeentitywithinthelast5years? 

12. Doesanyentityownorcontrolyourbusinessordoesyourbusinessownorcontrolanyentity? Yes

No 

13. Duringthepastfiveyears,hasyournamebeenchangedorhasanyotherbusinesspurchased, Yes

No 

mergedorconsolidatedwithyou? 

Forquestions9‐11,pleasefullyexplainany“yes”response,includingthenames,dates,andrevenueimpactinvolved:





14. Pleaselistanyassociationsofwhichyouareamember:



15. PleasedescribethenatureoftheApplicant’sbusiness(typeofproductorservicesprovided).  

  



1. Inthenext12months(orduringthepast24months)istheApplicantcontemplating(orhas 

theApplicantcompletedorbeenintheprocessofcompleting)thefollowing:



a. Anyactualorproposedmerger,acquisition,ordivestiture?Yes

No 

b. Anycreationofaneworganization,subsidiary,ordivision?Yes

No 

c. Anyreorganizationorarrangementwithcreditorsunderfederalorstatelaw?  Yes

No 

d. Anybranch,location,facility,office,orsubsidiaryclosings,consolidations,orlayoffs? Yes

No 

IfanyofthequestionsabovewereansweredYes,pleaseattachanexplanation,includingthetiming,

theessentialtermsoftheevent,arrangement,impactonemployeebaseandthesurroundingcircumstances.

GENERALINFORMATION

ORGANIZATIONINFORMATION

Page2of16



2. IstheApplicantmanagedoradministeredbyanythirdpartyundercontractoragreement? Yes No 

IfYes,pleaseattachanexplanation.



3. DoestheApplicantmanageoradministeranyentity(otherthantheApplicantEntity)under Yes

No 

contractoragreement?IfYes,pleaseattachanexplanation.



1. Totalassetsofallplanstobecovered:$



2. Totalnumberofemployeescoveredbyallplans:



3. Listthenamesofallemployeebenefitplansforwhichcoverageisrequested.(Completeaseparateplanquestionnaire

foreachplanlistedbelow.)







1. Completethefollowingchartprovidingtherequestedfinancialinformation:



Indicatethefollowingasitrelatesto

theApplicant’sfiscalyearend(FYE):

(Pleaseindicatenegativefigureswith“()”or“‐“asappropriate)

MostRecentFYE

(Month/Year)

(_____/_____)

PriorFYE

(Month/Year)

(_____/_____)

TotalAssets $ $

LongTermDebt $ $

NetEquity/NetAssets(DeficitEquity) $ $

Revenues $ $

NetIncome(NetLoss) $ $



2. IstheApplicantcurrently(orhasitbeeninthepast24months)inviolationof,orhas  Yes

No 

itreceivedanamendmenttoanydebtcovenant?

IfYes,pleaseattachanexplanation.



1. NumberofEmployees:FullTime:PartTime:



2. NumberofVolunteers:   Howmanyhoursperweekdovolunteersworkonaverage? 



NumberofIndependentContractors:  HowmanyworksolelyfortheApplicant?



3. PleasedescribetheservicesperformedbyVolunteersfororonbehalfofyourOrganization.





4. PleasedescribetheservicesperformedbyIndependentContractors:





REQUESTEDCOVERAGE

FINANCIALINFORMATION

EMPLOYEES(includingSubsidiaryemployeeinformationonaseparatesheet)

Page3of16



5. SalaryRangesNumberoffull  Numberofpart

(includingbonuses,dividendsandcommissions) timeemployees  timeemployees



$50,000orless:

$50,001to$100,000:

$100,001andover:

 TOTAL:  



Ifyouhavemultiplelocations,pleaselistthenumberofemployeesbystate:



tate:

tate:

tate:

tate:

tate:

Full‐Time 

Part‐Time 

Volunteers 

IndependentContractors 



6. DoestheApplicantuseseasonalortemporaryemployees? Yes

No 

Ifso,whenandhowmany?   

Aretheseemployeesincludedin#4above? Yes No 



7. DoestheApplicantuseleasedworkers? Yes

No 

IfYes,howmanyhavebeenretainedbytheApplicantinthepast12months?

Aretheseemployeesincludedin#5above? Yes No 



8. Howmanyemployeesarecoveredbycollectivebargainingorotherunionagreements?   



9. Inthepast12months,howmanyofficershaveleftyouremploy?   

Oftheabove,howmanywereterminated?   



10. Inthepast12months,howmanyotheremployeeshaveleftyouremploy?   

Oftheabove,howmanywereterminated?   



11. Inthepasttwelve(12)months,hasyourtotalnumberofemployeesdecreasedbymore Yes

No 

thantenpercent(10)orfive(5)employees,whicheverisgreater,throughanyreduction

inforce,systematiclay‐off,closureofanydivision,officeorfacilitythatyouownoroperate

orforanyotherreason?(IfYes,pleasecompletetheReductionInForcesupplement.)



12. Inthenext

twelve(12)months,doyouanticipatethetotalnumberofyouremployees Yes No 

todecreasebymorethantenpercent(10%)orfive(5)employees,whicheverisgreater,

throughanyreductioninforce,systematiclay‐off,closureofanydivision,officeorfacility

thatyouownoroperateorforanyotherreason?(IfYes,pleasecompletetheReduction

InForcesupplement.)



13. Ifduringthenext12months,circumstancesofwhichyouarecurrentlyunawaremakeit Yes No 

necessaryforyoutodecreasethenumberofyouremployeesbytenpercent(10%)orfive(5)

employees,whicheverisgreater,throughtheimplementationofanyreductioninforce,

systematiclayoff,closureofanydivision,officeorfacilitythatyouownoroperateorforany

otherreason(withany

suchreduction,lay‐offorclosurenotknown,anticipatedorplannedby

youasofthedateofthisApplication),doyouagreethatyouwillconsultwith,andadoptthe

adviceof,alawyerwhospecializesinlaborandemploymentlaw(mayincludein‐house

counsel,butonlyifthat

counselifqualifiedandexperiencedinthepracticeoflaborand

employmentlaw)asrespectstheimplementationofsuchreduction,lay‐offorclosure?

(IfNo,pleaseexplainonaseparatesheet.)

Page4of16



14. DoestheApplicantanticipateanymerger,acquisition,oradditionofanyoperationsthat Yes No 

wouldcompriseatwenty‐fivepercent(25%)orten(10)employees,whicheverisgreater,

increaseoverthecurrentnumberofemployees?(IfYes,pleaseprovidefulldetailsona

separatesheet.)



15. Hasanyinsurerevercancelledornon‐renewedtheApplicantoritspredecessorforthis Yes

No 

typeofcoverage?(IfYes,pleaseprovidedetailsonaseparatesheet.)



1. DoestheApplicanthavewrittenemploymentagreementswithallofficers? Yes

No 

2. HavetheApplicant’smanagersand/orsupervisorsattendedtrainingandeducationprograms/ Yes

No 

seminarsonsexualharassmentandothertypesofdiscriminationwithinthelast12months?

IfYes,whohasattended?   

IfYes,whoconductsthesessions?   

3. DoestheApplicanthaveitsemploymentpolicies/proceduresreviewedbylabororemployment Yes No 

counsel?

IfYes,identifythefirmanddateoflastreview:   

4. DoestheApplicanthaveaHumanResourcesorPersonnelDepartment? Yes No 

IfNo,whohandlesthisfunction?   

5. DoestheApplicanthaveanemployeehandbook? Yes No 

IfYes,doestheApplicantdistributeittoallemployees? Yes

No 

IfYes,doallemployeessignupforitsreceipt? Yes

No 

IfYes,doesitexpresslystatethatitisnotacontractandthatemploymentis“atwill”? Yes

No 

6. DoestheApplicanthavewrittenproceduresforhandlingemployeecomplaintsofdiscrimination Yes

No 

and/orsexualharassment?

7. DoestheApplicantrequireallterminationstobereviewedby:

 Thepersoninchargeofhumanresources? Yes

No 

 Outsidecounsel? Yes

No 

8. DoestheApplicantmaintainapersonnelfileforeachemployee? Yes

No 



1. AfterinquirywitheachpersonasappropriatedoesanyonehaveanyotherMaterialFactsto Yes

No 

 disclose?(IfYes,pleaseprovidesuchMaterialFactsonaseparatesheet.)



AMaterialFactisonelikelytoinfluenceassessmentofthisrisk,thepremiumchargedorthetermsandconditions

imposedbyUnderwriters.Ifyouareinanydoubtastowhetherafactwouldbeconsideredmaterial,

youshould

discloseit.Alloftheinformationrequestedinthisproposalismaterial.



1. Provideyourfirm’srecentFiduciaryLiabilityinsurancehistorybelow:



 Insurance

Company

LimitsPerClaim/

Aggregate Deductible

PolicyPeriod

(Month/Day/Year)

Retro

Date

Annual

Premium

CurrentYear   

HUMANRESOURCES

OTHERMATERIALINFORMATION

INSURANCEANDLOSSHISTORY

Page5of16



 Insurance

Company

LimitsPerClaim/

Aggregate Deductible

PolicyPeriod

(Month/Day/Year)

Retro

Date

Annual

Premium

PreviousYear1   

PreviousYear2   

PreviousYear3   

PreviousYear4   



2. a. DoesyourexpiringFiduciaryLiabilityInsurancepolicyincludeEmployeeBenefitsLiability Yes

No 

 (EBL)coverage?

b. DoesyourexpiringCommercialGeneralLiabilityInsurancepolicyincludeEmployee  Yes

No 

 BenefitsLiability(EBL)coverage?



Ifrequestingprioractscoverageyouwillbeaskeduponbindingcoveragetoprovideacopyofyourcurrentinsurance

declarationpagedocumentingtheexpiringretroactivedateandlimits.Prioractscoveragemaynotbeavailableifthe

dateofyourcurrentretroactivecoverageisdifferent

fromwhatwehavequotedorifthereisanygapbetween

effectivedates.



3. Areyoubeingcanceledornon‐renewedbyyourcurrentFiduciaryLiabilitycarrier? Yes

No 

 

IfYes,pleaseexplainwhy:



4. RequestedLimits:

$100,000/$300,000 $250,000/$250,000 $500,000/$500,000 $1,000,000/$1,000,000



Other$/$



RequestedDeductible(PerClaim):

$10,000 $25,000 $50,000 Other



5. Afterinquirywitheachpersonasappropriate,hasanyFiduciaryoranyDirectorsorOfficers Yes

No 

hadaFiduciaryLiabilityclaimorbeenallegedorfoundguiltyofanyFiduciarybreachofduty?



 If“Yes”,howmany? PleasecompleteaseparateSupplementalClaimFormfor Yes

No 

 eachclaimorsuitandincludeacurrentlyvaluedlossrunforeachclaim.



6. Afterinquirywitheachpersonasappropriate,doyouofanyFiduciary,oranyofyourpartners, Yes

No 

officers,directors,oremployeesknowofanycircumstances,acts,errors,omissions,oranyallegations

orcontentionsofanyincidentthatcouldresultinaFiduciaryLiabilityclaim? 



If“Yes,”howmany?If“Yes,”pleasecompleteaseparateSupplemental

ClaimFormforeachpotentialclaimandprovideasmuchdetailsaspossible.



Pleasefurnishuswiththefollowingdocumentationforeachplanforwhichcoverageisrequestedinthispolicy:



 Currentlyvalued5‐yearFiduciaryLiabilitylossruns.

 Copyofplanandtrustdocuments,andany

amendmentsmadethereto.

 Samplesofenrollment,cancellation,dispute,orotherformsusedfortheplans.

 Samplesofrecentnewslettersorotherwrittenplancommunicationdistributedtoparticipantsandbeneficiaries.

REQUIREDATTACHMENTS

Page6of16



 MostrecentForm5500.

 Foranyplanthatisdesignedtoinvestprimarilyinsecurities,themostrecentCPA‐auditedfinancialstatements.

 Foranyplan(orplanfeature)thatisdesignedtoprimarilyinvestinsecuritiesoftheSponsorOrganization,themost

recentCPA‐auditedfinancialstatementsand

acompletedESOPquestionnaireforeachplan.

 Foranyplanthatfiledforexemptionfromaprohibitedtransaction,acopyofthefilingandtheDOIresponse.

 LatestannualreportfortheSponsorOrganization.

 LatestinterimfinancialstatementsfortheSponsorOrganization.



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co mpany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.



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cl aim



fortheproceedsofaninsurancepolicycontaininganyfalse,incompleteormisleadinginformationisguiltyofafelony.



NOTICETOPENNSYLVANIAAPPLICA N TS: 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.

Page7of16



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DirectorofHumanResourcesoracurrentFiduciary)



Applicant’sSignature:   Date:



Agent/BrokerName:  





click to sign

signature

click to edit

Page8of16



PLAN SUPPLEMENTAL APPLICATION

Complete one plan questionnaire for EACH plan for which coverage is being requested.

1. Nameofplantobecovered:________________________________________________________________________



Totalassets(marketvalue):$__________________



2. IstheplanaMulti‐EmployerorMultipleEmployerPlan?Yes

No 



3. Numberofparticipantsandbeneficiariesoftheplan:____________________________________________________



4. ERISAQualifiedPlan?Yes

No 



5. TypeofEmployeeBenefitPlan:

Welfare DefinedBenefit DefinedContribution



6. ListthenamesofallFiduciariesnamedintheplan:

Administrator:__________________________________________________________________________________

InvestmentManager:_____________________________________________________________________________

DirectorsandOfficers:____________________________________________________________________________

_______________________________________________________________________________________________



OtherFiduciaries(listname/title/roletoplan):

_______________________________________________________________________________________________



7. Doestheplanholdanycontractwithaguaranteedreturn

[includingGuaranteedInvestmentContracts(GICs),Guaranteed

AnnuityContracts(GACs),orBankInvestmentContracts(BICs)]?Yes

No 



Ifyes,pleaseattachcompletedetails,includingnameofcontractprovider,themarketvalueofthecontract,andthedatethe

contractexpires.





PARTI:PLANDETAILS

KinsaleInsuranceCompany

P.O.Box17008

Richmond,VA23226

(804)289‐1300

www.kinsaleins.com

Page9of16



8. IfthereisERISAFidelityBondcoverageinforcewithanotherInsurer,pleaseindicatebelow.Ifnocoverageiscarried,check

here

.

a. Insurer:________________________________

b. LimitofLiability:_________________________

c. Premium:______________________________



9. HasanyERISAFidelityBondforthisplaneverbeenrefused,canceled,ornon‐renewed?  Yes

No 

(Ifyes,attachcompletedetails.)



1. DoestheplanemploytheservicesofaThirdPartyAdministrator?Yes

No 

(Ifyes,indicatethenameoftheorganizationandtheservicestheyprovidetotheplan.)

Actuarial:______________________________________________________________________________________

_______________________________________________________________________________________________

Administrative:_________________________________________________________________________________

_______________________________________________________________________________________________

BenefitsConsulting:______________________________________________________________________________

_______________________________________________________________________________________________

Legal:_________________________________________________________________________________________

_______________________________________________________________________________________________

Trustee:_______________________________________________________________________________________

_______________________________________________________________________________________________

Other:_________________________________________________________________________________________

_______________________________________________________________________________________________



2. Doesanon‐employeeInvestmentManagermanageallassets?Yes

No 

Ifyes:

HowoftenistheInvestmentManager'sperformancereviewed?

Monthly Quarterly Semi‐Annually Other(Ifother,pleaseattachexplanation.)



HowoftenaretheInvestmentManager'sguidelinesforinvestmentreviewedbytheFiduciaries?

Semi‐Annually Annually Bi‐Annually Other(Ifother,pleaseattachexplanation.)



Ifno,or"onlysome"assetsareinvestedbyanInvestmentManager,pleaseattachanarrativeexplanation.



3. HasanyFiduciaryoftheplanbeen:

a. ThesubjectofanyallegedbreachofdutyorotherFiduciaryLiabilityClaim?  Yes

No 

b. Foundguiltyofabreachofduty?Yes

No 

c. FoundguiltyunderanycriminalactenumeratedinSection411ofERISA?   Yes

No 

d. RefusedcoverageunderanERISAFidelityBond?Yes

No 



Iftheanswertoanyoftheaboveisyes,pleasecompleteaFiduciaryLiabilityClaimSupplemental.



PARTII:PLANADMINISTRATION

Page10of16



4. CompletethefollowingchartofprofessionalsthatcurrentlyworkwiththeApplicant:

TypeofProfessional NameofPerson NameofCompany(or

Employer)

Location(city) Yearsworking

withplan

RiskManager(or

equivalentposition)



GeneralCounsel 

Outsidelawfirmfor

benefitsandERISA

litigation





5. Whocontrolsthedocumentationabouttheplanthatisdistributedtoparticipantsandbeneficiaries?

______________________________________________________________________________________________

Isthereaprocesstoreviewdocumentationbeforeitisdistributed?Yes

No 

(Ifyes,pleaseattachacopyoftheprocedureorexplaintheprocessinanattachment.)



1. Hastheplanrequestedorcontemplatedfilingarequestfortermination?Yes

No 

(Ifyes,attachcompletedetails.)



2. Inthepasttwoyears,havetherebeenanyamendmentstotheplan,orhasanyamendmentbeencontemplated,thathas

resultedinormayresultinanychangeorreductionofbenefits,includingbutnotlimitedtoanincreaseinparticipants'share

costs?Yes No 

(Ifyes,attachcompletedetails.)



3. Hastheplanoranyportionoftheplanbeen

spunoff(sold), transferred,or terminated?

Ifno,checkhere

.



Ifyes,attachcompletedetails,including:

 Dateofsaleortermination

 Whetherassetshavebeenfullydistributedorrevertedtoapartyotherthantheplanparticipants

 Nameofannuityprovider,ifbenefitshavebeensecuredbyannuities



4. Inthelast12months,hasthere

beenanymerger,acquisition,restructuring,orconsolidationoforbytheSponsor

Organization,oranyofitssubsidiaries,thatresultedinormayresultinplanparticipantstransferringtoanotherplan,

company,orsubsidiary?Yes

No 



Isanysuchactionbeingconsidered?Yes

No 



Ifyesforeitherquestion,attachcompletedetails,including:

 Date(orexpecteddate)ofthetransferofbenefits

 Copiesofmaterialsdistributed(ortobedistributed)toEmployeesrelatingtothetransferofbenefits

 Mostrecentfinancialstatementsforanycreatedoracquiredsubsidiaries



5. Has

therebeen,oristherenowpending,anyclaim(s)againstanyproposedInsuredarisingoutofthisplan?

Yes

No 

(Ifyes,attachcompletedetails.)



PARTIII:PLANACTIVITIES

Page11of16



6. DoesanyproposedInsuredhaveknowledgeorinformationofanyact,error,oromission,whichmightgiverisetoaclaim

undertheproposedpolicy?Yes

No  

 (Ifyes,attachcompletedetails.)



7. Isthereanyknownviolation(s)ofERISA,oranysimilarcommonorstatutorylawoftheUnitedStates,Canada,oranystateor

otherjurisdictionanywhereintheworld,towhichtheplanissubject?   Yes

No  

 (Ifyes,attachcompletedetails.)



8. Hastherebeenoristherenowpendinganyinquiry,investigation,orcommunicationwhichcouldgiverisetoaclaimunder

thispolicy?Yes

No  

 (Ifyes,attachcompletedetails.)



1. QuestionsthatapplytoDefinedBenefitPlansONLY.IfthisisNOTaDefinedBenefitplan,skiptoPartV:

a. Whendidtheplan'senrolledactuarylastcertifytheplansAdjustedTargetFundingAttainmentPercentage(ATFAP)?

Date:_________________________________



b. Arethere

anyoverdueemployercontributionsfortheplan,orhastheplanrequestedorcontemplatedfilinga

requestforawaiverofcontributions?Yes

No  

 (Ifyes,attachcompletedetails,includingtheamountoverdue.)



c. Istheplancurrentlyoperatingunderafundingimprovement/rehabilitationplanorsubjecttoanybenefitrestrictions

pursuanttothePensionProtectionActof2006?Yes

No  

 (Ifyes,attachcompletedetails.)



1. Istheplanaqualified401(k)plan?Yes

No 

 (Ifyes,answerallquestionsbelow.)



a. Listthecurrentinvestmentoptionsthatareavailabletotheparticipantsoftheplan,alongwiththeirrespectiverisks:



NameofInvestmentOption LevelofRisk(CheckOne)

Low Medium High

 



b. Howoftencanparticipantstypicallymakechangesintheallocationoftheirinvestmentsintheplan?



Quarterly Monthly Weekly Daily Other



Ifother,pleaseexplain:__________________________________________________

_____________________________________________________________________



c. Havetherebeenanyblackoutperiodsinthepast12monthsthatpreventedparticipantsfrommakingchangesinthe

allocationoftheirinvestments?Yes

No 



PARTIV:DEFINEDBENEFITPLANS

PARTV:DEFINEDCONTRIBUTIONPLANS

Page12of16



Ifyes,listfirstdate_________andlastdate________ofblackoutperiod.



d. Whoprovidesinvestmentguidancetotheparticipantsoftheplan?

NameofAdviser:_________________________________________________

TitleofAdviser:__________________________________________________

CompanythatemploystheAdviser:__________________________________



e. Howoftenisinvestmentguidancemadeavailabletoemployees?

Annually Semi‐Annually Quarterly Monthly Availableuponrequest



Iflessthanannually,pleaseexplain:________________________________________

______________________________________________________________________



f. Canparticipantschoosetoinvestinemployerstockinthe401(k)plan?   Yes

No 

Ifyes,whatistheactualdollarvalueofplanassetsinvestedinemployerstock?__________



Ifyes,whatisthelimittothepercentageofassetsthatcanbeinvestedinemployerstock?

Nolimit 10% 20% Other



Ifother,pleaseexplain:___________________________________________________



g. Doesthecompanycontributeany"matchingfunds"tothe401(k)accounts?  Yes

No 

Ifyes,howarethefundscontributed?

CashValue EmployerStock Other



Ifother,pleaseexplain:____________________________________________



Ifmatchingfundsarecontributedinemployerstock,arethererestrictionsthatpreventtheparticipantfrommoving

thatstocktoanotherinvestment?Yes

No 



Ifyes,howlongistheemployeerequiredtowaitbeforemovingthestock?________



h. IsanyFiduciaryofthis401(k)planalsoacompanyDirector,Officer,orEmployeewhohasaccesstocompany

financialstatementsandotherfinancialinformation?Yes

No 

 (Ifyes,attachcompletedetails.)



2. Istheplandesignedtoinvestprimarilyinemployersecurities?Yes

No 

 (Ifyes,pleasecompleteandattachanESOPQuestionnairetoyourapplication.)



FRAUDWARNING



NOTICETOALABAMA,ALASKA, ARIZONA,ARKANSAS,CALIFORNIA,CONNECTICUT,DELAWARE,GEORGIA,IDAHO, ILLINOIS,INDIANA,IOWA,KANSAS,

MARYLAND,MASS ACHUSETTS,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

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co mpanyoragentofan insurancecompanywhoknowinglyprovidesfalse, incompleteormisleadingfactsorinformationtoapolicyholderor

proceedsshallbe

reportedtotheColoradoDivisionofInsurancewithintheDepartmentofRegulatoryAgencies.



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.



Page13of16



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 clai m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.



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cl aim

fortheproceedsofaninsurancepolicycontaininganyfalse,incompleteormisleadinginformationisguiltyofa

felony.



NOTICETOPENNSYLVANIAAPPLICA N TS: 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.



Signed:Date:

 (MustbesignedbyacurrentFiduciary.)



PrintName:



Title:



Page14of16



FIDUCIARY

LIABILITYSUPPLEMENTALCLAIMAPPLICATION



  ThisformistobecompletedwhentheApplicanthasbeeninvolvedinanyclaimorisawareofanincidentwhich

maygiverisetoaclaim.COMPLETEONEFORMFOREACHCLAIMORINCIDENT.

  Ifspaceisinsufficienttoansweranyquestionsfully,attachaseparatesheet.

  Inlieuofattachingsuitpapers,pleaseprovideacompletenarrativedescriptionoftheallegationsinvolved



1. FullNameofApplicant:



2. FullNameofIndividual(s)orentityinvolvedintheclaim:



3. NameofthePlan(s)involvedintheclaim:



4. Additionaldefendants



5. FullNameofClaimant:



6. IstheClaimantstillyourclientafterbringingtheclaim? Yes

No 



Beforeorafterthisclaim,didyouperformotherprofessionalservicesforthisClaimantunrelated Yes

No 

tothisclaim?



IfYestoeitherquestion,pleaseexplain.    

 



7. Beforethisclaim,hadyousuedorotherwisepursuedcollectioneffortsagainsttheClaimantfor Yes

No 

unpaidfeesforyourprofessionalservices?



8. Indicatewhether:

CLAIM SUIT Incident/CircumstanceOnly(noclaimorsuit)



9. Dateandlocationofallegedact,errororomission:



10. Dateofclaim:DatereportedtoInsuranceCompany:



11. Whatisthestatusoftheclaim? Closed/Settled

 Open/Pending  Incident/Circumstance 



12. IFCLOSED:

Totalpaidincludingdeductible(s)?Responsessuchas“unknown”or“unavailable”areinsufficient.

 Defensecosts Loss/compensatorydamages

Paidbyyou‐outofpocket $ $

InsuranceCompany $ $



 DateResolved:_____/_____/_____ Trial

  OutofCourt 

APPLICANT’SINFORMATION

KinsaleInsuranceCompany

P.O.Box17008

Richmond,VA23226

(804)289‐1300

www.kinsaleins.com

Page15of16



13. IFPENDING:

(a) Claimant’ssettlementdemand?$ _____Defendant’ssettlementoffer(ifany):$

(b) Insurer’sreserveamounts?Loss$Defense$

(d) Whatisyourbestestimateofthelikelysettlementamountforthismatter?$

(e) Whatisyourbestestimateofthedatewhenyouexpectthisclaimtoberesolved?

Note:Answering“unknown”or“unavailable”totheabovequestionsisaninsufficientresponse.



14. Name(s)ofInsurer(s)respondingtothisclaimorincident

PolicyNumber:

LimitsofLiability:Deductible:



15. Providenarrativedescriptionofsuit,claimorincident,includingtheallegationsinvolved,thepotentialsizeofinjury

andyourresponse:





16. Explainwhataction(s)havebeentakentopreventreoccurrenceofasimilarclaim:  ______ 

_____



Ideclarethattheinformationsubmittedhereinistruetothebestofmyknowledgeandbecomesapartofmy

ProfessionalLiabilityApplication.Iunderstandthatanincorrectorincompletestatementcouldvoidmy

protection.



 

 SignatureofApplicant/Title/Date (MustbesignedbyaPrincipal,PartnerorOfficeroftheFirm)



FRAUDWARNING



NOTICETOALABAMA,ALASKA, ARIZONA,ARKANSAS,CALIFORNIA,CONNECTICUT,DELAWARE,GEORGIA,IDAHO, ILLINOIS,INDIANA,IOWA,KANSAS,

MARYLAND,MASS ACHUSETTS,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 knowing ly, and with intent to defraud any insurance company or other person, files an

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co mpanyoragentofan insurancecompanywhoknowinglyprovidesfalse, incompleteormisleadingfactsorinformationtoapolicyholderor

proceedsshallbe

reportedtotheColoradoDivisionofInsurancewithintheDepartmentofRegulatoryAgencies.

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.



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.



Page16of16



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su bjectto

criminalandcivilpenalties.



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

oftheclaimforeachsuchviolation.



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APPLICA N TS: 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.



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.



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Name:    



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Fiduciary Liability Application - Fiduciary_Liability_Application

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