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ProfessionalServicesSupplement

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FDIC #: ___________________________
DATE: ___________________________
Professional Services Supplemental Application
*To be able to save this form after the elds are lled in, you will need to have Adobe Reader 9 or later. If you do not have
version 9 or later, please download the free tool at: http://get.adobe.com/reader/.
THE LIABILITY POLICY THAT MAY BE ISSUED BASED UPON THIS APPLICATION PROVIDES CLAIMS MADE
COVERAGE WRITTEN ON A NO DUTY TO DEFEND BASIS. DEFENSE COSTS ARE INCLUDED WITHIN THE LIMIT OF
LIABILITY AND REDUCE THE LIMIT OF LIABILITY AVAILABLE TO PAY SETTLEMENTS AND JUDGMENTS. PLEASE
READ THE POLICY CAREFULLY.
Applicant (Parent Company): ____________________________________________________ FDIC #: _____________________________
Representative authorized to receive notices on behalf of the Applicant and all subsidiaries:
Name: _______________________________________ Title: _________________________ Email: ______________________________
Complete only the sections applicable to the professional services offered by the Applicant.
1. a. Indicate the agency performing and the date of the last two regulatory exams of the EDP operation:
Agency that Performed Regulatory Exam Date of Regulatory Exam
b. Were there any criticisms or comments noted in the most recent regulatory exam of the EDP operations?
If yes, attach details including if appropriate corrective action has been taken.
Yes
No
2. Does the Applicant or any Subsidiary provide: (a) computer consulting services, including software, hardware,
systems or telecommunication analysis; (b) systems integration services; or (c) designing, developing, selling,
licensing, distributing, installing or servicing computer software services?
Yes
No
If yes, complete question 3.
3. Provide the most recent annual fees or revenue from each of the following services:
Service Most Recent Annual Fees or Revenue
a. Computer consulting, including software, hardware, systems
analysis and telecommunications.
b. Systems Integration
c. Designing, developing, selling, licensing, distributing, installing
or servicing computer software.
General Information
Data Processing Services
Complete only if Data Processing Services are provided.
Security National Insurance Company Wesco Insurance Company
AmTrust Insurance Company of Kansas
(all states except: AZ, CT, DE, FL, LA and NJ) (applies to: AZ, CT, DE, FL and NJ) (LA only)
SUPPAPPL 03 2013 Page 1 of 7
Insurances Services
Complete only if Insurance Services are provided.
Insurance Services include: a. Offering credit life, accident, and disability insurance; b. Services as an insurance agent
or broker involving individual life, health, accident or disability insurance, individual or commercial property or casualty
insurance products; c. The purchase or sale of annuities; d. Any other insurance or risk management related services.
Data Processing Services includes a. Accounting/payroll services, accounts payable/receivable; b. Cost and general
accounting; c. Management reporting; d. Computer consulting, including software, hardware and systems analysis; e.
Designing, selling, installing or servicing computer software; f. Microche services.
SUPPAPPL 03 2013 Page 2 of 7
1. Complete the following information pertaining to the scope of Insurance Services provided:
Commercial Lines
Annual Gross Fee
Income or Revenue
Personal Lines
Annual Gross Fee
Income or Revenue
a. Automobile a. Automobile (standard)
b. Aviation b. Automobile (non-standard)
c. Bonds c. Homeowners
d. Directors & Ofcers Liability d. Credit Life Accident & Disability
e. Non-Medical Professional Liability Accident & Health and Life
f. Medical Malpractice a. A & H Group
g. Ocean and Inland Marine b. A & H Individual
h. Excess and Surplus Lines c. Annuities or Mutual Funds
i. Workers Compensation d. Life Group
j. Standard Property & Casualty e. Life Individual
2. Is there a written policy and procedures manual for insurance services addressing the following areas:
a. Conrm all verbal binders promptly, and in writing, to both client and carrier?
Yes
No
b. Maintain a policy expiration list (including direct bill) and make certain all policies are renewed and all
binders issued on time?
Yes
No
c. Check all policies and endorsements for accuracy and completeness before mailing?
Yes
No
d. Maintain a written procedure for all licensed personnel to read all policy forms prior to using?
Yes
No
e. Maintain a system to immediately notify the insurance carrier of all claims and incidents reported to
the agency by Insured or third party claimants?
Yes
No
f. Maintain a suspense system for following up on receipt of requested items?
Yes
No
g. Conduct internal audits to monitor compliance with errors and omissions procedures?
Yes
No
e. Require annual attendance of brokers and agents at errors and omissions seminars?
Yes
No
f. A policy that prohibits the placement of insurance with carriers rated lower than A- by A.M. Best
Company, or that are not rated?
Yes
No
3. Are any of the following insurance related services provided: If yes, attach details.
Yes
No
a. Sale of annuities
Yes
No
b. Third-Party administrative services
Yes
No
c. Claims adjusting services
Yes
No
d. Program administrator or MGA for any insurance program
Yes
No
e. Loss control services
Yes
No
f. Insurance company
Yes
No
Investment Adviser / Financial Planning Services
Complete only if Investment Adviser/Financial Planning Services are provided.
Investment Adviser/Financial Planning Services include: a. Registered investment adviser; b. Financial planning; c. Asset
allocation; d. Wealth asset management; e. Economic forecasting.
1. Does the Applicant or any Subsidiary act as an Investment Adviser pursuant to the Investment Advisers
Act of 1940? If yes, complete questions 2 through 15.
Yes
No
2. Are investments in specialty areas other than securities (e.g. futures, forwards, swaps, precious metals,
options, restricted securities, real estate, and limited partnerships) recommended?
Yes
No
If yes, attach details.
3. Are there written policies and procedures addressing the following areas:
a. Investment and regulatory compliance
Yes
No
b. Accurate pricing of securities
Yes
No
c. Accurate trade executions
Yes
No
SUPPAPPL 03 2013 Page 3 of 7
4. When the Applicant succeeds another investment adviser is a hold harmless agreement executed?
Yes
No
5. Do all registered investment advisers maintain professional designations such as CFP, CFA or have the
equivalent training and expertise?
Yes
No
6. Are there written policies and procedures addressing the following areas:
a. Investment and regulatory compliance
Yes
No
b. Accurate pricing of securities
Yes
No
c. Accurate trade executions
Yes
No
7. When the Applicant succeeds another investment adviser is a hold harmless agreement executed?
Yes
No
8. Do all registered investment advisers maintain professional designations such as CFP, CFA or have the
equivalent training and expertise?
Yes
No
9. Provide the following information regarding registered Investment Adviser services provided by the Applicant:
Account Information Current Year Prior Year
a. Total asset value of all accounts
b. Percent of total assets under management that are discretionary
c. Percent of total assets under management that are non-discretionary
d. Asset value of largest account
e. Total number of accounts
f. Annual fees for investment advisory services
Account Information Market Asset Value No. of Accounts
a. Individual
b. Trusts
c. ERISA and Non-ERISA Pension Plans
d. Institutional
e. Other (please explain)
10. Does the Applicant or any Subsidiary provide Financial Planning Services?
Yes
No
11. Indicate the number of nancial plans completed in the past two years:
Year Financial Plans Completed
12. Do nancial planners also sell nancial products to implement the recommended nancial plan for the client?
Yes
No
If yes, has a conict of interest policy been adopted and implemented?
Yes
No
13. Do all nancial planners maintain professional designations such as CFP, CFA or have the equivalent
training and expertise?
Yes
No
14. Does the Applicant or any Subsidiary publish any newsletter or other publication providing investment
advice or opinions on investments?
Yes
No
If yes, does any such publication contain disclaimers regarding the advice provided?
Yes
No
15. Does the Applicant or any Subsidiary provide any economic forecasting services?
Yes
No
SUPPAPPL 03 2013 Page 4 of 7
Real Estate Services
Complete only if Real Estate Services are provided.
Real Estate Services include: a. Real estate agent or broker; b. Real estate appraisals; c. Property management; d. Title
Abstracter; e. Title agent services.
1. Does the Applicant or any Subsidiary provide Real Estate Agent or Real Estate Broker Services?
Yes
No
If yes, complete questions 24 through 25.
2. For the most recent year, provide the following information:
Real Estate Portfolio Number Properties Sold
Total Dollar Value of
Properties Sold
Commission
a. Commercial
b. Residential
c. Other
Total
3. Indicate the number of ofcers or employees who are licensed real estate brokers or agents:
4. Does the Parent Company or its Subsidiaries provide real estate appraisal services?
Yes
No
If yes, are all real estate appraisers required to obtain professional certication and belong to
related professional associations?
Yes
No
5. Does the Parent Company or its Subsidiaries provide Property Management Services?
Yes
No
If yes, complete questions 28 through 31.
6. For the most recent year, provide the following information:
Real Estate Portfolio
Number Properties
Managed
Estimated Dollar Value of
Properties Managed
Management Fees
a. Commercial
b. Residential
c. Other
Total
7. Indicate by checking the box which Property Management Services are provided:
a. Accounting/Bookkeeping
Yes
No f. Security System Maintenance
Yes
No
b. Evictions
Yes
No g. Mortgage Payments
Yes
No
c. General Maintenance
Yes
No h. Rent Collection
Yes
No
d. Insurance Payments
Yes
No i. Safety Inspections
Yes
No
e. Investigate and Handle
Tenant’s Complaints
Yes
No
8. Does the Parent Company and its Subsidiaries require a hazardous waste survey before accepting any
appointment as manager of real estate properties? If no, attach details.
Yes
No
9. Does the Parent Company and its Subsidiaries have specic guidelines regarding the maintenance of
insurance on managed real estate properties? If no, attach details.
Yes
No
10. Does the Parent Company or its Subsidiaries provide any of the following real estate services?
a. Abstractor
Yes
No
b. Auctioneer
Yes
No
c. Closing Ofcer
Yes
No
d. Escrow Agent
Yes
No
e. Title Agent
Yes
No
SUPPAPPL 03 2013 Page 5 of 7
Security Broker / Dealer Services
Complete only if Security Broker/Dealer Services are provided.
Security Broker/Dealer Services include: a. Purchase or sale of securities by a registered broker/dealer;
b. Discount brokerage services.
1.
Indicate the number of registered representatives: _____________
2. a. Indicate the average total daily trading volume: $ _____________
b. Indicate the average per account daily trading volume: $ _____________
c. Indicate the highest trading volume on any one day in the most recent past year: $ _____________
3. Are margin accounts offered?
Yes
No
If yes, state the percentage of total volume represented by margin accounts: % ____________
4. State the percentage of broker/dealer revenues which are derived from the following:
Investment Trade
% of Broker/Dealer
Revenues
Investment Trade
% of Broker/Dealer
Revenues
a. Listed Stock h. International Securities
b. Unlisted Stocks i. Mutual Funds
c. Bonds j. Limited Partnerships
d. Unregistered Bonds or Securities k. Direct private Placement
e. Commercial Paper l. Market Making/Specialist
f. Options Contracts m. Underwriting
g. Commodity Futures n. Other (attach full details)
5.
Does the brokerage department clear its own trades?
Yes
No
If no, indicate the name and location of the broker or clearing agent utilized:
6.
Do all contracts contain an arbitration provision?
Yes
No
7.
Has a registered representative answered “Yes” to question 22 of such registered representative’s
FORM U-4?
Yes
No
If yes please provide copies of such FORM U-4.
8. Are discount brokerage services offered?
Yes
No
If yes, does the contract or other literature distributed to clients clearly dene the Insured’s
responsibility and specically indicate that no investment advice will be given?
Yes
No
Trust Department Liability Services
Complete only if Trust Department Liability Services are provided.
1.
Year Trust Department was established: _______________
2. Number of trust ofcers: _____________________________ Average years of trust ofcer experience: _______________________
3. Please provide annual gross revenues (in thousands) of the Trust Department for the past 3 years:
Year 1: $ _______________ Year 2: $ _______________ Year 3: $ _______________
4. Please provide the following information, showing asset amounts in thousands:
Type of Account
No. of
Accounts
Book Value
of Assets
Managed/
Discretionary
Advisory/
Nondiscretionary
Custodial
Individual $ % % %
ERISA $ % % %
Corporate $ % % %
Other $ % % %
Total $ % % %
SUPPAPPL 03 2013 Page 6 of 7
Other Professional Services
Complete only if Professional Services other than those identied in the preceding sections is provided.
Fraud Warning
Any person who knowingly and with intent to defraud any insurance company or another person les 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 may be a crime and may subject the
person to criminal penalties.
ALABAMA, ARKANSAS, LOUISIANA, NEW JERSEY, NEW MEXICO, RHODE ISLAND, VIRGINIA and WEST VIRGINIA: Any person who knowingly presents a false or
fraudulent claim for payment of a loss or benet or knowingly presents false information in an Application for insurance is guilty of a crime. In Alabama, Arkansas, Louisiana, Rhode
Island and West Virginia that person may be subject to nes, imprisonment or both. In New Mexico, that person may be subject to civil nes and criminal penalties. In Virginia, penalties
may include imprisonment, nes and denial of insurance benets.
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, nes, 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.
DISTRICT OF COLUMBIA, KENTUCKY and PENNSYLVANIA: Any person who knowingly and with intent to defraud any insurance company or other person les an Application
for insurance or statement of claim containing 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. In District of Columbia, penalties include imprisonment and/or nes. In addition, the Insurer may deny insurance benets if the Applicant
provides false information materially related to a claim. In Pennsylvania, the person may also be subject to criminal and civil penalties.
FLORIDA and OKLAHOMA: Any person who knowingly and with intent to injure, defraud or deceive the Insurer, les a statement of claim or an Application containing any false,
incomplete or misleading information is guilty of a felony. In Florida it is a felony to the third degree.
5. Are there written Trust Department policies and procedures addressing all of the following:
a. Approval of new accounts?
Yes
No
b. Approval of closing accounts?
Yes
No
c. Reviewing accounts on a periodic basis for compliance with trust terms?
Yes
No
d. Approval of the purchase and sale of trust assets?
Yes
No
e. The need for legal review of trust documents and changes to trust terms?
Yes
No
f. Acceptable criteria for trust investments?
Yes
No
g. Conict of interest, including investments in nancial instruments of the Parent Company or its subsidiaries?
Yes
No
h. Providing nancial reports to clients?
Yes
No
i. The use of formal checklists to document which administrative trust duties (payment of taxes, insurance,
etc.) are performed and when they are performed?
Yes
No
If any of the above are not addressed, provide details by attachment.
6. As of the most recent Trust Department regulatory examination:
a. Were any conict of interest criticisms rendered?
Yes
No
b. Were there any other criticisms of Trust Department operations or management? If yes, attach details.
Yes
No
7. Is the Trust Department subject to a Cease and Desist Order, Memorandum of Understanding or similar
action by any Regulatory Authority? If yes, attach details.
Yes
No
8. Does the Trust Department have an approved list of securities?
Yes
No
If not, attach details on the criteria used for investment selections.
9. Does the Trust Department manage any common trust funds?
Yes
No
If yes, attach copy of the most recent CPA audit of each fund.
10. Are nancial reports sent to Trust Department clients on a monthly basis?
Yes
No
11. Is a hold harmless agreement protecting the Trust Department from the liabilities of a previous trustee
obtained when the Trust Department succeeds an outside trustee?
Yes
No
12. Does the Trust Department control 5% or more of the stock of any corporation?
Yes
No
If yes, attach a listing of such corporations including the percentage held.
13. Does the Trust Department perform shareholder accounting services for mutual funds? If yes, provide details.
Yes
No
14. Does the Trust Department provide actuarial services for clients? If yes, provide details.
Yes
No
15. Is the Trust Department involved in the actual operations of any farms, ranches, or other real estate, oil, gas,
mineral, timber or other natural resource leases, or other types of client business?
Yes
No
If yes, attach full details including the number of clients and total assets involved.
16. Are any services provided outside a trust agreement, such as investment advice, tax planning, etc.?
Yes
No
If yes, attach details including the qualications of the persons providing such services.
Other Professional Services include: a. Accounting and tax preparation services; b. Actuarial services; c. Travel agent services.
1. Attach a list of such Professional Services including a description of the nature of the Professional Service,
the professional training, qualications or designations maintained by the employees that provide such
Professional Services and the number of employees holding such designations.
2. Are there any special auditing or internal control procedures in place with respect to any Other Professional
Service provided?
Yes
No
800 Superior Avenue E., 21st Floor • Cleveland, OH 44114 • Phone: 866.327.6904 • Fax: 216.328.6251 • www.amtrust.com
Submit applications to: banksubmissions@amtrustgroup.com
SUPPAPPL 03 2013 Page 7 of 7
MKT0813 4/15
Please provide the following information with your submission:
• Current Declarations Page from the Applicant’s Financial Institution Bond, D&O Policy, Bankers Professional Liability Policy,
Trust Errors & Omissions Policy, Employment Practices Liability Policy and/or Kidnap & Ransom Policy, if such bond/policies
are not currently written by AmTrust North America.
• Most recent Annual Report or audited nancial statements. If not applicable, attach a copy of the most recent Directors’
Examination Report.
• Management Letter and Applicant’s responses to any recommendations made therein.
• If applicable, most recent Form 10-K, 10-Q and any other Registration Statement led with the SEC within the past 12 months.
Submit Application to:
banksubmissions@amtrustgroup.com
AmTrust North America
Attention: Financial Institution Division
800 Superior Avenue E., 21st Floor • Cleveland, OH, 44114
Phone: 866.327.6904 • Fax: 216.328.6251
www.amtrustnorthamerica/nancial-institutions.com
Representation Statement
The undersigned declare that, to the best of their knowledge and belief, the statements in this Application, any prior Applications, any additional material submitted, and any publicly
available information published or led by or with a recognized source, agency or institution regarding business information for the Applicant for the 3 years prior to the Bond/
Policy’s inception [hereinafter called “Application”] are true, accurate and complete, and that reasonable efforts have been made to obtain sufcient information from each and every
individual or entity proposed for this insurance. It is further agreed by the Applicant that the statements in this Application are their representations, they are material and that the
Bond/Policy is issued in reliance upon the truth of such representations.
The signing of this Application does not bind the undersigned to purchase the insurance and accepting this Application does not bind the Insurer to complete the insurance or
to issue any particular Bond/Policy. If a Bond/Policy is issued, it is understood and agreed that the Insurer relied upon this Application in issuing each such Bond/Policy and any
Endorsements thereto. The undersigned further agrees that if the statements in this Application change before the effective date of any proposed Bond/Policy, which would render
this Application inaccurate or incomplete, notice of such change will be reported in writing to the Insurer immediately.
Chief Executive Ofcer, President or Chairman of the Board:
Print Name: ________________________________________________ Signature: ____________________________________________
Title: ______________________________________________________ Date: ________________________________________________
Chief Financial Ofcer or Equivalent Ofcer:
Print Name: ________________________________________________ Signature: ____________________________________________
Title: ______________________________________________________ Date: ________________________________________________
A BOND/POLICY CANNOT BE ISSUED UNLESS THE APPLICATION IS SIGNED AND DATED BY TWO INDIVIDUALS
Agent Name: _______________________________________________ License Number: ______________________________________
Agent Signature: ____________________________________________
KANSAS: 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 benet pursuant to an insurance policy for personal or commercial insurance which such person knows to contain
materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto is considered a crime.
MAINE: 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, nes or denial of insurance benets.
MARYLAND: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benet or knowingly or willfully presents false information in an
Application for insurance is guilty of a crime and may be subject to nes and connement in prison.
OHIO: Any person who, with intent to defraud or knowing that he is facilitating a fraud against the Insurer, submits an Application or les a claim containing a false or deceptive
statement is guilty of insurance fraud.
OREGON: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benet or knowingly presents false information in an application for insurance may be
guilty of a crime and may be subject to nes and connement in prison.
TENNESSEE 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 may include imprisonment, nes and/or denial of insurance benets.
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ProfessionalServicesSupplement

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Completed 2 July 2020

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