Fillable Trust Trustee PL Supplemental Application

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Trust Trustee PL Supplemental Application

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Page 1 of 4
TRUST/TRUSTEE
SUPPLEMENTAL
PROFESSIONAL
LIABILITY APPLICATION
(SUBMIT WITH LAWYERS PROFESSIONAL LIABILITY APPLICATION)
Firm Name:
Please provide the following regarding Trustee services. Complete a separate supplement for each Trust. Note: Do not complete for
nonfunded Trust. For these Trusts, in lieu of an application, please provide a list of identifying the Trust and Trustee.
1. Name of the Trust:
2. Name of Trustee:
3. Does the Trustee engage in any of the following activities? If so, please provide an explanation in the space provided on
the second page of this supplement.
(a) Use the Trust funds to invest in entities in which the Trustee, Firm, or related Yes No
individual or entity is involved.
(b) Employment by the Trust of persons or agents who are owners or employees Yes No
of the firm or related to the Trustee or Firm.
(c) Use of Trust funds as loans to the Trustee, owners, or employees of the Firm Yes No
or the Firm itself.
4. Firm’s Services:
Services
Yes or No
Provided by
Trustee
Provided by Other
Firm Member
Reviewed By
Position in
the Firm
Bookkeeping Yes No
Bill Paying Yes No
Tax Yes No
Investment Decisions Yes No
Other (describe):
Yes No
5. The relationship prior to the Trusteeship:
Family Member New Client
Long Time Client No relationship prior to Trusteeship
Other (describe):
6. Fees for Trustee services are determined by:
Trust Agreement Direct Billing to Trustor Other (describe):
7. Do Trustee fees inure to the benefit of the Trustee or to the Firm? Yes No
PART 1 – TRUSTEEE INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 4
1. Please provide the following for any current or prior trust work for the past 36 months:
Date Appointment
Accepted
Asset Value of Trust
Annual Trust Income
Number of Trust
Beneficiaries
Type of Trust
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
2. Is an accounting provided to all beneficiaries? Yes No
If “YES”, how frequently? Monthly Quarterly Annually As Requested
Other:
3. Does anyone else receive a copy of the accounting? Yes No
If “YES”, who?
1. Please list specific duties of the Trustee, or provide a copy of the Trustee duties section of the Trust document.
2. Does the Trustee delegate any Trustee duties to others? Yes No
If “YES”, please describe the procedures in place to monitor the acts of others performing Trustee services.
1. Please describe the extent of the Trustee’s authority to invest funds and/or authorize loans.
2. Please describe the composition of the Trustee investments.
PART 2 – TRUST INFORMATION
PART 3 – RESPONSIBILITIES
PART 4 – TRUST INVESTMENTS
Page 3 of 4
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.
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.
Page 4 of 4
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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Trust Trustee PL Supplemental Application

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Completed 2 July 2020

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