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NOTICE

ALL LIABILITY COVERAGE PARTS FOR WHICH APPLICATION IS MADE APPLY, SUBJECT TO THEIR TERMS,

ONLY TO CLAIMS FIRST MADE OR DEEMED MADE AGAINST INSUREDS DURING THE POLICY PERIOD OR

ANY EXTENDED REPORTING PERIOD, IF APPLICABLE. THE LIMIT OF LIABILITY AVAILABLE TO PAY

LOSSES WILL BE REDUCED BY THE AMOUNTS INCURRED AS DEFENSE EXPENSES, AND DEFENSE

EXPENSES WILL BE APPLIED AGAINST THE RETENTION AMOUNT. THE COMPANY HAS NO DUTY TO

DEFEND ANY CLAIM UNLESS DUTY–TO-DEFEND COVERAGE IS SPECIFICALLY PROVIDED.

The term Ap

plicant means all corpor

ations, organizations or other entities, including subsidiaries, proposed for this

insurance.

I. GENERAL INFORMATION

1. Applicant Information:

Name of Applicant:

Street Address:

City, State, ZIP Code:

Website Address:

Year Applicant’s business was established:

Description of Applicant’s operation:

2. Applicant’s Standard Industrial Classification (SIC) code, if known (4-digit number):

3. Is the Applicant a subsidiary of a foreign parent? Yes No

4. Does the Applicant currently file, or does it anticipate filing in the next 6 months, any documents

with the Securities and Exchange Commission, or similar foreign authority regarding any equity or

debt securities? Yes

II. ORGANIZATION INFORMATION

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 business, subsidiary or division? Yes No

c. Any registration for a public offering or a private placement of securities? Yes No

d. Any reorganization or arrangement with creditors under federal or state law? Yes No

e. 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, and the surrounding circumstances.

III. EMPLOYEE INFORMATION

1. Maximum number of employees at any one point during the previous 12 months for the following classifications

(regardless of whether they are full or part time):

FRI-1100W-IND Ed. 01-09 Printed in U.S.A. Page 1 of 7

Fiduciary Liability

Coverage Application

Travelers Casualty and Surety Company of America

FRI-1100W-IND Ed. 01-09 Printed in U.S.A. Page 2 of 7

Total Employees

(Including leased, union, independent

contractors and temporary employees)

Leased

Labor

Unions

Independent

Contractors

Temporary

IV. FINANCIAL INFORMATION

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

it received an amendment to any debt covenant? Yes

If Yes, please attach an explanation.

Note: Omit Question 2 if the Applicant is required to submit a separate financial statement as directed in the Required

Attachments section.

2. 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)

(_____/_____)

Current Assets $ $

Total Assets $ $

Current Liabilities $ $

Long Term Debt $ $

Retained Earnings (Accumulated Deficit/Fund Deficit) $ $

Net Equity/Net Assets (Deficit Equity) $ $

Revenues $ $

Net Income (Net Loss) $ $

V. AUDITOR INFORMATION

1. Has the Applicant changed outside auditors in the last 12 months? N/A Yes No

If Yes, please attach an explanation.

2. Has any auditor issued a “going concern” opinion in any financial statements

of the Applicant during the past 12 months? N/A

Yes No

If Yes, please attach an explanation.

VI. PLAN DATA

1. Premium to be paid by: Employer: Trust or Plan:

2. Complete the chart for all plans for which coverage is requested:

Full Plan Name

*Plan

Type

Current

Asset Value

Latest FYE

Annual

Contributions

Current # of

Participants

**Plan

Status

$ $

*Plan Types: Defined Benefit (DB) Defined Contributions (DC) ESOP (E) Self-Funded Welfare Benefit Plan

(W) Other (O) – Attach Explanation

**Plan Status: Active (A) Frozen (F) Sold (S) Terminated (T) (If any plan has been terminated, indicate date of

transaction)

List any additional plans on a separate attachment.

FRI-1100W-IND Ed. 01-09 Printed in U.S.A. Page 3 of 7

VII. PLAN UNDERWRITING QUESTIONS

1. Is each plan reviewed periodically to assure there are no violations of ERISA (e.g., prohibited

transactions or party-in-interest rules)? Yes

If No, please attach an explanation.

2. Does any plan (a) not conform to the standards of eligibility, participation, vesting, blackout

notification requirements and other provisions of ERISA or similar foreign law, or (b) hold

employer securities or employer real property in violation of ERISA or in excess of ERISA limits? Yes

If Yes, please attach an explanation.

3. Has any plan (a) been the subject of an investigation by the DOL, IRS, or any similar foreign

agency; (b) had its tax exempt status withdrawn or threatened to be withdrawn by the IRS;

to its financial condition by an independent public accountant? Yes

If Yes, please attach an explanation.

4. If any plan is a defined benefit plan, has such plan (a) experienced an event reportable to

the PBGC; (b) not been certified by an actuary to be adequately funded in accordance with

ERISA’s minimum funding standard; or (c) been converted into a cash balance plan or is

any such conversion expected in the next 12 months? If there are no defined benefit

plans, please check “N/A”. N/A

Yes No

If Yes, please attach an explanation.

5. Has any plan (a) been amended within the last 12 months in a way that will result in the

reduction of benefits or are any such amendments anticipated within the next 12 months;

or (b) been merged with another plan, terminated or sold within the past 2 years or is any

such merger, termination or sale anticipated in the next 12 months? Yes

If Yes, please attach an explanation detailing the implementation, disclosure and any

relevant blackout periods.

6. Are there any outstanding or delinquent plan contributions or plan loans, leases or debt

obligations that are in default or classified as uncollectible? Yes

If Yes, please attach an explanation.

7. Does the employer, committee or employer representatives, or union board of trustees

have final say over the determination of whether benefits will be paid under any healthcare

plan sponsored by the Applicant? Yes

If Yes, please identify the names of such plans in a separate attachment.

8. Does any plan invest in a mutual fund, collective trust or similar investment pool that

receives investment management services from the Applicant for a fee? Yes

If Yes, please attach an explanation.

9. Please provide name of firm(s) providing the following services:

CPA Attorney Actuary Investment Advisor

VIII. CURRENT INSURANCE INFORMATION/REQUESTED INSURANCE TERMS

Requested

Limit

(A)

Requested

Retention

(B)

Requested

Effective Date

(C)

Coverage Currently

Purchased

(D)

$ $ Yes No

Expiring

Limit

(E)

Expiring

Retention

(F)

Expiring

Premium

(G)

Current

Insurer

(H)

Date Coverage

First Purchased

(I)

$ $ $

FRI-1100W-IND Ed. 01-09 Printed in U.S.A. Page 4 of 7

1. What is the Applicant’s preference for defense coverage? Duty to Defend Reimbursement

2. If Liability Coverage is currently purchased as indicated in Column (D) above, but has

been in place for less than 3 years, please answer the following question:

As of the date the Applicant first purchased the Liability Coverage, is the Applicant

or any person proposed for this insurance aware of any fact, circumstance, situation,

event or act that reasonably could give rise to a claim being made against them under

the Liability Coverage for which the Applicant is applying? Yes

If Yes, please attach an explanation.

3. If Liability Coverage is not currently purchased as indicated in Column (D) above,

please answer the following question:

Is the Applicant, or any person proposed for this insurance aware of any fact,

circumstance, situation, event or act that reasonably could give rise to a claim

against them under the Liability Coverage for which the Applicant is applying? Yes

If Yes, please attach an explanation.

4. If the Requested Limit in Column (A) exceeds the Expiring Limit in Column (E), please

answer the following question:

Solely with respect to any higher limits requested or that may ultimately be issued for the

proposed insurance, is the Applicant or any person proposed for this insurance aware of

any fact, circumstance, situation, event or act that reasonably could give rise to a claim

against them under the Liability Coverage for which the Applicant is applying? Yes

If Yes, please attach an explanation.

With respect to the information required to be disclosed in response to the questions above, the proposed insurance will

not afford coverage for any claim arising from any fact, circumstance, situation, event or act about which any executive

officer of the Applicant had knowledge prior to the issuance of the proposed policy, nor for any person or entity who knew

of such fact, circumstance, situation, event or act prior to the issuance of the proposed policy.

IX. LOSS INFORMATION

1. In the past 3 years, whether or not insured, has any plan, Applicant, or person proposed for

this insurance been accused or found guilty of any criminal act or been accused of, found guilty

of or held liable for a breach of fiduciary duty, or a violation of ERISA, or any similar state, local

or foreign law or have any ERISA-related claims, administrative or regulatory proceedings,

charges, hearings or demands been made? Yes

If Yes, please complete the table below:

Date of

Such

Claim

Nature of

Claim

Amount

Paid

for

Defense

Amount

Sought

or Paid for

Damages

Covered by

Insurance?

Corrective

Procedures

Implemented

Current

Status

$ $ Yes No

To enter more information, please attach a separate page to the Application.

X. REQUIRED ATTACHMENTS

As part of this Application, please submit the following documents (these documents, and the representations and facts

they contain, are made a part of this Application, whether such documents are physically delivered to the Company by the

Applicant or are obtained by the Company from any public source, including the Internet):

 Sponsor financial statement if Applicant maintains a defined benefit, self-funded welfare plan, an Employee Stock

Ownership Plan (ESOP) or if the Applicant is a church, government or quasi-governmental entity

 Plan financial statements for defined benefit plans and self insured welfare plans, if limit requested is greater than

$1,000,000

 Sponsor financial statement and plan financial statements for each defined contribution plan, if limit requested is

greater than $5,000,000

FRI-1100W-IND Ed. 01-09 Printed in U.S.A. Page 5 of 7

 Employer Securities Supplemental Application, if any plan is an ESOP or if any other defined contribution plan invests

in employer securities

 Most recent 5500 of all plans

XI. COMPENSATION NOTICE

Important Notice Regarding Compensation Disclosure

For information about how Travelers compensates independent agents, brokers, or other insurance producers, please

visit this website: http://www.travelers.com/w3c/legal/Producer_Compensation_Disclosure.html

If you prefer, you can call the following toll-free number: 1-866-904-8348. Or you can write to us at Travelers,

Enterprise Development, One Tower Square, Hartford, CT 06183.

XII. FRAUD WARNINGS

Attention: Insureds in Alabama, Arkansas, D.C., Maryland, New Mexico, and Rhode Island

Any person who knowingly (or willfully in MD) presents a false or fraudulent claim for payment of a loss or benefit or

who knowingly (or willfully in MD) presents false information in an application for insurance is guilty of a crime and may

be subject to fines and confinement in prison.

Attention: Insureds in 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, 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 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.

Attention: Insureds in Florida

Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an

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

Attention: Insureds in Kentucky, New Jersey, New York, Ohio, and Pennsylvania

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 conceals for the purpose of misleading,

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

such person to criminal and civil penalties. (In New York, the civil penalty is not to exceed five thousand dollars

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

Attention: Insureds in Louisiana, Maine, Tennessee, Virginia, 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 include imprisonment, fines, and denial of insurance benefits.

Attention: Insureds in Oregon

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly

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

confinement in prison.

Attention: Insureds in Puerto Rico

Any person who knowingly and with the intention of defrauding presents false information in an insurance application,

or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or

presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be

sanctioned for each violation with the penalty of a fine of not less than five thousand dollars ($5,000) and not more than

ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should

aggravating circumstances be present, the penalty thus established may be increased to a maximum of five (5) years; if

extenuating circumstances are present, it may be reduced to a minimum of two (2) years.

XIII. SIGNATURE SECTION

THE UNDERSIGNED AUTHORIZED REPRESENTATIVE (PARTNER, PRINCIPAL, TRUSTEE OR OTHER OFFICER

ACCEPTABLE TO TRAVELERS) OF THE APPLICANT DECLARES THAT TO THE BEST OF HIS/HER KNOWLEDGE

AND BELIEF, AFTER REASONABLE INQUIRY, THE STATEMENTS SET FORTH IN THE ATTACHED TRAVELERS

NEW BUSINESS OR RENEWAL APPLICATION FOR INSURANCE ARE TRUE AND COMPLETE AND MAY BE

FRI-1100W-IND Ed. 01-09 Printed in U.S.A. Page 6 of 7

RELIED UPON BY TRAVELERS. IF THE INFORMATION IN ANY APPLICATION CHANGES PRIOR TO THE

INCEPTION DATE OF THE POLICY, THE APPLICANT WILL NOTIFY THE COMPANY OF SUCH CHANGES, AND

THE COMPANY MAY MODIFY OR WITHDRAW ANY OUTSTANDING QUOTATION. THE COMPANY IS

AUTHORIZED TO MAKE INQUIRY IN CONNECTION WITH THIS APPLICATION.

FRI-1100W-IND Ed. 01-09 Printed in U.S.A. Page 7 of 7

THE SIGNING OF THIS APPLICATION DOES NOT BIND THE COMPANY TO OFFER, NOR THE APPLICANT TO

PURCHASE, THE INSURANCE. IT IS AGREED THAT THIS APPLICATION, INCLUDING ANY MATERIAL

SUBMITTED THEREWITH, SHALL BE THE BASIS OF THE INSURANCE AND SHALL BE, IN ALL STATES OTHER

THAN NC AND UT, CONSIDERED PHYSICALLY ATTACHED TO AND PART OF THE POLICY, IF ISSUED. THE

COMPANY WILL HAVE RELIED UPON THIS APPLICATION, INCLUDING ANY MATERIAL SUBMITTED

THEREWITH, IN ISSUING THE POLICY.

ELECTRONICALLY REPRODUCED SIGNATURES WILL BE TREATED AS ORIGINAL.

Signature* of Applicant’s Authorized Representative Name (Printed)

(Partner, Principal, Trustee or Officer)

Title Date

*IF YOU ARE ELECTRONICALLY SUBMITTING THIS APPLICATION TO TRAVELERS, APPLY YOUR ELECTRONIC

SIGNATURE TO THIS FORM BY CHECKING THE ELECTRONIC SIGNATURE AND ACCEPTANCE BOX BELOW.

BY DOING SO, YOU HEREBY CONSENT AND AGREE THAT YOUR USE OF A KEY PAD, MOUSE, OR OTHER

DEVICE TO CHECK THE ELECTRONIC SIGNATURE AND ACCEPTANCE BOX CONSTITUTES YOUR SIGNATURE,

ACCEPTANCE, AND AGREEMENT AS IF ACTUALLY SIGNED BY YOU IN WRITING AND HAS THE SAME FORCE

AND EFFECT AS A SIGNATURE AFFIXED BY HAND.

AUTHORIZED REPRESENTATIVE’S ELECTRONIC SIGNATURE AND ACCEPTANCE

XIV. PRODUCER INFORMATION (ONLY REQUIRED IN FLORIDA, IOWA, AND NEW HAMPSHIRE):

Producer Signature Producer Name (Printed)

Agency Name Agency Code License Number

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