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
No
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
© 2009 The Travelers Companies, Inc. All Rights Reserved
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
© 2009 The Travelers Companies, Inc. All Rights Reserved
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
No
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
© 2009 The Travelers Companies, Inc. All Rights Reserved
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
No
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
No
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;
(c) filed for an exemption from a prohibited transaction; or (d) received an adverse opinion as
to its financial condition by an independent public accountant? Yes
No
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
No
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
No
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
No
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
No
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
© 2009 The Travelers Companies, Inc. All Rights Reserved
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
No
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
No
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
No
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
No
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
$ $ 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
© 2009 The Travelers Companies, Inc. All Rights Reserved
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
© 2009 The Travelers Companies, Inc. All Rights Reserved
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
© 2009 The Travelers Companies, Inc. All Rights Reserved
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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