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INVESTMENT COUNSELING/MONEY MANAGEMENT SUPPLEMENTAL APPLICATION (Risk Placement Services, Inc.)

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MALP 0013 07 13 Page 1 of 3
INVESTMENT COUNSELING/MONEY MANAGEMENT SUPPLEMENTAL APPLICATION
NOTE: For purposes of this Supplemental Application, the following definitions apply:
1. "Investment Counseling" means any verbal or written advice, opinion, or recommendation that you have
provided to any party relative to the financial merits or desirability of making, or not making, any particular
financial investment.
2. "Money Management" means any investment decisions or choices or actual investments you have made
on behalf of any party.
APPLICANT’S INSTRUCTIONS:
This form is to be completed if the Applicant showed any activity in the Investment Counseling/Money Management area
of practice shown in Section II. "Applicant's Practice," on the main application. If space is insufficient to answer any
question fully, attach a separate sheet. Answer all questions completely.
APPLICANT:
1. a. Pl
ease indicate below the total number of clients you have, along with your total annual gross revenues from both
commissions and fees derived from Investment Counseling and/or Money Management activities for the past two
(2) calendar years, and the projected totals for the current calendar year.
YEAR NUMBER OF CLIENTS TOTAL ANNUAL GROSS REVENUES
Current
b. For the revenue projected for the current year listed in 1.a. above, please indicate the approximate percentage
derived from:
SERVICE PERCENTAGE OF
REVENUE
Financial Planning Fees %
Investment Advisory Fees %
Commissions from Life/Health/Disability Product Sales %
Commissions from Mutual Fund, Annuity, Stocks/Bonds, Derivatives, Real
Estate Investment Trust, Unregistered Securities
%
Benefit/Pension Plan Counseling %
Accounting Service
%
Business Management Counseling %
Economic Forecasting %
Asset or Client Fund Management %
Discretionary Investment Authority %
Other (Please attach an explanation) %
Total (Must Equal 100%)
%
Broker Name
Broker Street
Broker City, State, Zip
Deerfield Insurance Company
Evanston Insurance Company
Essex Insurance Company
Markel American Insurance Company
Markel Insurance Company
Associated International Insurance Company
MALP 0013 07 13 Page 2 of 3
2. Please check each box below if, during the past two (2) years, you have recommended to any party that they make
that type of an investment, or if you have made that type of an investment on behalf of any of your past or present
clients.
Stocks or Bonds Private Placements
Commodities, Options, Derivatives or Currencies Venture Capital Investing
Mutual Funds Commercial Real Estate
Hedge Funds Real Estate Development
Limited Partnerships Other (Describe)
3. a. Do you have custody or possession of any investment assets or funds that belong to another
party?
Yes No
b.
4. During the past two (2) years, have any of the following occurred relative to any past or present
Investment Counseling or Money Management client? Please check either Yes or No for each
question. If Yes to any part of Question 4. below, please attach complete details on a separate
sheet.
a. Has any entity that you have invested in on behalf of any party, or that you have recommended
that any party invest in, ceased operations, or gone insolvent, bankrupt, or into receivership or
liquidation?
Yes No
b. Have you, or anyone at the Applicant, drafted a will, trust, or other document under which you,
any relative of yours, or anyone at the Applicant is a beneficiary?
Yes No
c. Have you, or anyone at the Applicant, ever been active in the management or operation of any
investment vehicle (except under the auspices of a will, trust, or family limited partnership)?
Yes No
d. Have you, or anyone at the Applicant, been the subject of any regulatory inquiry or action of any
kind by the SEC , the NASD, or any other federal or state governmental agency?
Yes No
e. Have you, or anyone at the Applicant, ever had any kind of business or professional license
suspended or revoked?
Yes No
I understand the information submitted herein becomes a part of my Professional Liability Insurance Application and is
subject to the same representations and conditions.
Notice to Florida Applicants: 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 in the
third degree.
Notice to New York Applicants: 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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for
each such violation.
Signature of Owner, Officer or Partner Print or Type Name and Title Date (month-day-year)
Producers Must Complete:
Produced By (Insurance Agent or Broker):
Producer Name: Producer Signature:
Producer License No.: Date:
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MALP 0013 07 13 Page 3 of 3
Notice to Alabama Applicants; 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 is guilty of a crime and may be subject to
restitution, fines, or confinement in prison, or any combination thereof.
Notice to Arkansas, District Of Columbia, New Mexico, Rhode Island And West Virginia 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 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 policyholder 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 Kansas Applicants: It is unlawful to commit a “fraudulent insurance act” which means an act committed by any
person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief
that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of,
or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial
insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance
which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the
purpose of misleading, any information concerning any fact material thereto.
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 Maine, Tennessee, Virginia and Washington 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 Maryland Applicants: Any person who knowingly or willfully presents a false or fraudulent claim for payment of
a loss or benefit or who knowingly or willfully 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 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 Ohio Applicants: Any person who, with intent to defraud or knowing that he 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 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 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.
Notice to Vermont Applicants: Any person who knowingly presents a false statement in an application for insurance may be
guilty of a criminal offense and subject to penalties under state law.
Notice to Applicants of all other 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 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.
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INVESTMENT COUNSELINGMONEY MANAGEMENT SUPPLEMENTAL APPLICATION (Risk Placement Services, Inc.)

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Completed 23 November 2020

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