Fillable Financial Planners Professional Liability Application

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Financial Planners Professional Liability Application

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The Financial Planners Professional Liability Application form is 9 pages long and contains:

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Page 1 of 9
FINANCIAL PLANNERS PROFESSIONAL LIABILITY INSURANCE APPLICATION
1. Legal name of the business who is the primary applicant and will be the first named insured listed on the policy:
2. Please list all other business/dba names for which you are seeking coverage under this policy:
3. Corporation Individual Partnership Municipality For Profit Joint Venture
Other:
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. Primary location address:
6. County of primary location: Date business originally established:
7. Total number of branches? List all addresses for additional branches:
8. What is your web-site address? www.
9. What is your phone number?
10. 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?
11. Does any entity own or control your business or does your business own or control any entity? Yes No
12. 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:
13. Please list any associations of which you are a member:
1. Firm Staff (include contract and per diem employees who work 500 or more hours per year):
Registered
Investment Advisor
Non-Registered
Advisor
Other Total
Owners, Partners, Officers
All Other Financial Planners
Other Consulting Professionals
(not included above)
Administrative Staff
TOTAL
2. Does any member of the Applicant Firm hold any professional license other than as a Certified Yes No
Financial Planner or Investment advisor? Please list:
APPLICANT’S INFORMATION
GENERAL INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 9
3. Provide gross annual revenues derived from financial planning, advisory activities, commissions and/or product sales.
Annual Total Gross
Revenues (100%)
% Fee Only Revenues
% Commission
Revenues
No. of Financial
Advisors
Last Fiscal Year $ % %
Current Fiscal Year
(Estimated)
$ % %
Next Fiscal Year
(Projected)
$ % %
Percentage of revenue from the Firm’s largest clients (including related entities):
Largest
________% Second Largest _________
%
In reference to the Firm’s fee based clients please list:
Net worth – Less than $1MM
_____ % $1-5MM ______ % Greater than $5MM ________
%
4. Provide professional services by approximate percentage. Must equal 100%.
% NATURE OF PRACTICE % NATURE OF PRACTICE
Accounting Services Other Than Tax
Preparation
Discretionary Asset Management (LPOA) Hourly Advice
Divorce Financial Consulting Referral to Third Party Managers
Investment Management Consulting (No LPOA) Tax Preparation
Preparation/Advice
Third Party Pension Administration
Non-Discretionary Asset Management (LPOA With
Prior Consent)
Timing Services
Product Sales Based on Financial Plan Wrap Accounts
Product Sales Not Based on Financial Plan Other (please describe):
5. As an advisor, does the Applicant provide advice on, recommended or use alternative investments? Yes No
If yes, please describe:
If Yes, provide the percentage of the Applicant’s total practice advice and/or portfolio use that the following alternative
investments represent to the total advice and/or assets managed. Do not include investments that are used within a
mutual fund.
% Type of Investment % Type of Investment
Commodity Futures Derivative Instruments
Hedge Funds/Fund of Hedge Funds Foreign Securities Excluding ADR’s
Investment Related Real Estate General or Limited Partnerships
Mortgages, mortgage pools, mortgage backed
securities
Promissory Notes
Options Contracts REITS Privately Traded
Private Placements Tangibles (gold, silver, collectibles, coins, etc.)
Unrated Bonds Other:
Unregistered Securities
Page 3 of 9
6. Does the Applicant receive commissions? Yes No
If Yes, provide a breakdown of total commission income by percent. Must equal 100%.
% Type of Product % Type of Product
Investment Grade Bonds Foreign Securities/ADR’s
Junk Bonds General or Limited Partnerships
Life/Health/Disability/Accident Sales/Long Term
Care
Hedge Funds or Fund of Hedge Funds
Listed Stocks Options/Futures/Tangibles/CMO’s/
Derivatives
Mutual Funds Private Placements
Unlisted Stocks
Promissory Notes/Leases/Receivables
Variable Annuities REITS other than REIT Mutual Funds
Viatical Agreements/Senior Settlements/Life
Settlements
Unregistered Securities
Other – Please Describe
7. Please provide the following:
Accounts
Total # of
Accounts
Total Asset
Value
(current
year)
Total
Asset
Value
(prior
year)
Asset Value
of Largest
Account
Percentage Non-
Discretionary
Percentage
Discretionary
ERISA Fiduciary Plans
Non-ERISA Pension and
Employee Benefits Plans
Multi-Employer (Taft Hartley),
union or governmental
employee benefit plans
Mutual Funds
Personal Accounts (individual,
trust, families and estates)
Corporate/Institutional
Accounts
Others (please specify)
GRAND TOTAL
8. (a) Number of accounts lost in the last twelve (12) months:
(b) Total assets under management for accounts lost in the last twelve (12) months: $
(c) Reasons for loss of accounts:
9. Is any client a Mutual Fund, Hedge Fund, REIT, limited partnership or private placement? Yes No
Please explain:
10. Does the Applicant direct trades in client’s custodial accounts? Yes No
Page 4 of 9
If Yes, complete the following:
(a) Use a written Investment Policy Statement for other than ERISA accounts?
Yes No
(b) Have Limited Power of Attorney to direct trades in the client’s account?
If Yes, please answer:
Yes No
The Applicant uses full discretion to trade without prior consent of the client.
The Applicant uses discretion to trade within an Investment Policy Statement or written
parameters.
The Applicant declines to exercise discretion and obtains prior consent for each and every
trade.
(c)
Excluding advisory fees and authorized disbursement to an account with the same registration
or the client, does the Applicant have power to withdraw/disburse funds in the account?
Yes No
(d) Custodians: Fidelity TD Ameritrade Schwab Pershing FISERV Assetmark
NATC SSG Other:
(e) Are any assets under management invested in Exchange Traded Funds? Yes No
If Yes, what percentage of:
(i) Total assets under management are invested in Exchange Traded Funds?
_________
(ii) Exchange Traded Funds are leveraged? %
%
11. Has the Firm or any Firm member within the past five (5) years:
(a) Advised clients to invest in any entity in which any firm member or family member Yes No
has more than a 5% ownership interest in?
(b) Held an equity interest in, operated or managed any entity (excluding the Firm) for Yes No
whom the Firm provided professional services.
(c) Acted as a director, offer or exercised any form of managerial control over any entity Yes No
(excluding the Firm), for whom the Firm provided professional services?
If yes to any of the above, please explain.
12. Compliance:
(a) Is an “approved” list of securities maintained? Yes No
Are exceptions allowed and if so, how are they handled? Yes No
(b) Identify the name, title and years of experience of the person in charge of risk management Yes No
and/or compliance.
(c) Are any risk management and/or compliance activities provided by outside service providers? Yes No
If yes, Please explain:
(d) How often is compliance with investment and/or ERISA guidelines monitored? Yes No
13. Has the firm or any member of the firm who coverage is sought ever:
(a)
Had a professional license or registration denied, suspended, revoked, nonrenewed or
restricted?
Yes No
(b)
Been formally reprimanded by any court, administrative or regulatory agency? Yes No
(c) Had a complaint filed with any consumer agency, state securities department, insurance
department or the Applicant’s broker-dealer, SEC, NASD, or other regulatory agency?
If yes, please provide a copy of the complaint, response, and final ruling.
Yes No
(d) Been audited by the SEC, NASD, any state securities department, or other licensing or
regulatory agency? If Yes, provide a copy of the audit letter and the Applicant’s response.
Yes No
(e) Been formally accused of violating any professional association’s code of ethics? Yes No
Page 5 of 9
(f) Been convicted of a felony?
Yes No
(g) Been involved in or is aware of any fee disputes including suits?
If yes, please list the total number in the past 12 months, the amount in dispute, and the
status of litigation.
Yes No
(h) Ever had a trading error loss in excess of $5,000? If Yes, provide details including dates,
amounts and by whom the loss was paid.
Yes No
Provide details to any question that is answered “Yes”.
1. Provide your firm’s recent insurance history below:
Insurance Company
Limits Per
Claim/Aggregate
Policy Period
(Month/Day/Year)
Deductible
Annual Premium
Current Year
Previous Year 1
Previous Year 2
Previous Year 3
Previous Year 4
2. If you are currently insured for professional liability coverage, what is your policy’s retroactive date? (month/date/year)?
____/_____/______ If there is no retroactive date, please check here.
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 professional liability carrier? Yes No
If Yes, please explain why:
4. Requested Limits: $100,000/$300,000 $500,000/$500,000 $1,000,000/$1,000,000
$2,000,000/$2,000,000 Other $ /$
Requested Deductible (Per Claim): $5,000 $10,000 $25,000 Other
5. After inquiry with each person as appropriate, in the last five (5) years, has any professional liability Yes No
claim or suit ever been made against the Firm or any predecessor firm or any current or former
member of the Firm or predecessor firm?
INSURANCE AND LOSS HISTORY
Page 6 of 9
If “Yes,” how many? Please complete a separate Supplemental Claim Form
for each claim or suit and include a currently valued loss run for each claim.
6. After inquiry with each person as appropriate, do you, or any of your partners, officers, Yes No
directors, or employees know of any circumstances, acts, errors, omissions, or any allegations
or contentions of any incident that could result in a 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 attach the most recent form of the following:
(1) Form ADV Part I
(2) Form ADV Part II
(3) A sample contract for all professional services provided.
(4) A copy of any written SEC or other regulatory audits performed in the last three years and the Applicant’s
written response.
(5) Financial Statements
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.
Page 7 of 9
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.
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 Principal, Partner, or Officer of the Firm)
Applicant’s Signature: Date:
Agent/Broker Name:
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Page 8 of 9
PROFESSIONAL
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. Additional defendants
4. Full Name of Claimant:
5. Indicate whether: CLAIM SUIT Incident/Circumstance Only (no claim or suit)
6. Date and location of alleged act, error or omission:
7. Date of claim: Date reported to Insurance Company:
8. What is the status of the claim? Closed/Settled Open/Pending Incident/Circumstance
9. 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
10. IF PENDING:
(a) Claimant’s settlement demand? $ _____
(b) Insurer’s reserve amounts? Loss $ Defense $
Defendant’s settlement offer (if any): $
(c) Amounts already spent defending the claim? By you? $ By the insurer? $
(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.
11. Name(s) of Insurer(s) responding to this claim or incident
Policy Number:
Limits of Liability: Deductible:
APPLICANT’S INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 9 of 9
12. Provide narrative description of suit, claim or incident, including the allegations involved, the potential size of injury
and your response:
13. 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)
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Financial Planners Professional Liability Application

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Completed 2 July 2020

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