Fill - Free fillable Fiduciary Plan Questionnaire - Fiduciary_Plan

Kinsale

Insurance Company

P. O. Box 17008

Richmond, VA 23226

(804) 289-1300

www.kinsaleins.com

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

Page 2 of 7

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 3 of 7

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 of 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 4 of 7

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: __________________________________________________

_____________________________________________________________________

PART IV: DEFINED BENEFIT PLANS

PART V: DEFINED CONTRIBUTION PLANS

Page 5 of 7

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

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.)

Page 6 of 7

FRAUD WARNING

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

KANSAS, MARYLAND, MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW

HAMPSHIRE, NORTH CAROLINA, NORTH DAKOTA, OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT,

WASHINGTON, WEST VIRGINIA, WISCONSIN, AND WYOMING APPLICANTS: In some states, any person who knowingly, and with intent to

defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false

information, or, for the purpose of misleading, conceals information concerning any fact material thereto, may commit a fraudulent insurance

act which is a crime in many states.

NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance

company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance

and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or

information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a

settlement or award payable for insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory

Agencies.

NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose

of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits

if false information materially related to a claim was provided by the applicant.

NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a

statement of claim containing any false, incomplete or misleading information is guilty of a felony of the third degree.

NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of

a loss or benefit is a crime punishable by fines or imprisonment, or both.

NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an

application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact

material thereto commits a fraudulent insurance act, which is a crime.

NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly

presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the

purpose of defrauding the company. Penalties may include imprisonment, fines, or denial of insurance benefits.

NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is

subject to criminal and civil penalties.

NOTICE TO NEW MEXICO APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or

knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.

NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an insurance company or other person files an

application for insurance or statement of claim containing any materially false information, or conceals, for the purpose of misleading, information

concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed

$5,000 and the stated value of the claim for each such violation.

NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits

an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes a

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

NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company, or other person, files

an application for insurance or statement of a claim containing any materially false information or conceals for the purpose of misleading,

information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects the person to criminal and

civil penalties.

NOTICE TO TENNESSEE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for

the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

NOTICE TO VIRGINIA APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for

the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

Page 7 of 7

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: __________________________________________

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