FIDUCIARY LIABILITY INSURANCE

NOTICE: THE POLICY FOR WHICH APPLICATION IS MADE APPLIES, SUBJECT TO ITS TERMS, ONLY TO ANY “CLAIM” FIRST MADE OR DEEMED MADE AGAINST THE "INSURED" DURING THE POLICY PERIOD. THE LIMIT OF LIABILITY AVAILABLE TO PAY DAMAGES OR SETTLEMENTS MAY BE REDUCED BY THE AMOUNTS INCURRED AS "DEFENSE EXPENSES", AND "DEFENSE EXPENSES" MAY BE APPLIED AGAINST THE DEDUCTIBLE AMOUNT.

APPLICATION

* = Required

Agent/Broker

Code:

Name *

Policy Number:

I. General Information

1. Name & Address of Insured (Sponsor Organization): *

5. Annual Sales or Revenues: $

6. Is this a Publicly Traded Entity?:

Yes

7. Years in Business:

2. Description of Named Insured’s Business:

EIN#:

SIC Code:

8. Sponsorship:

Single Employer or Controlled Group of Corporations
Multi-Employer (Collectively-bargained)
Multi-employer	Church
Multiple Employer	Governmental
Other (Explain)

3. Total Number of Employees or Members: *

4. Maximum number of individuals in your workforce in the following capacities over the past 12 months:

Temporary:

Leased:

Independent Contractors:

* For Single Employer/Controlled Group of Corporations or Governmental Sponsors indicate employees. For all other sponsors use total members.

INSURANCE INFORMATION

1. Expiring Fiduciary Liability Coverage:

Limit	Deductible
Eff/Exp Date	Premium
Insurer

4. Premium Payable:

Annually

Three Years Installment

Three Years Prepaid

Premium to be Paid By:

Employer or Union

Trust or Plan

(Endorsement will be issued to eliminate recourse on insureds who are fiduciaries if the premium is paid by the Employee Benefit Plan. Premium for this endorsement must be paid from funds other than the assets of the Employee Plan.)

2. Coverage Requested:

Limit	Deductible
Eff/Exp Date

3. Insurance Representative (The individual acting as the exclusive agent to act on behalf of the Insureds in matters of this insurance):

LOSS INFORMATION

1. Has any plan, entity or person proposed for this insurance been:

(a)	Accused or found guilty or held liable for a breach of fiduciary duty, or a violation of ERISA, or any similar state, local or foreign law? Yes No
(b)	Accused or found guilty of any criminal act? Yes No

2. Has any fiduciary liability or fidelity coverage for any plan, entity or person proposed for this insurance ever been refused, canceled or non-renewed?
Yes No

PRIOR COVERAGE (select one)

I.	New Policy with no prior similar coverage:
	(a)	Are there any facts or circumstances which may result in a claim under the proposed policy? Yes No
II.	New Policy with prior similar coverage with another insurer (Attach a copy of the prior application for request for continuity of coverage):
		Yes No
	(a)	Prior similar coverage has been continually in effect since / / . At the time of original application to the insurer who wrote such coverage, were there any facts or circumstances which might have resulted in a claim being made against any insured? Yes No
	(b)	Are there any pending claims? Yes No
	(c)	During the past five years, have any claims been brought against any plan, entity or person proposed for this insurance? Yes No
III.	Renewal Policy of the Company:
	(a)	Prior similar coverage has been continually in effect with Travelers Property Casualty or any current or former affiliates since / / .
	(b)	Prior to obtaining coverage with Travelers Property Casualty or any current or former affiliates, similar coverage has been continually in effect with another insurer since / / .

(If Yes to any question above, attach details including type and amount of claim and whether any insurance responded.)

PLAN DATA

Complete Chart for all plans for which coverage is requested. For each plan listed, indicate in the corresponding column the applicable letter(s) and number.

Plan Type (Column 2)	Fund Status (Column 4)	Plan Status (Column 8)
Defined Benefit (DB) Defined Contribution (DC) Welfare Benefit Plan (W) Other (O) -Attach Explanation	1. Trust 2. Trust and Insurance 3. Insurance 4. Funded exclusively from general assets of the Sponsor (unfunded) 5. Funded partially from insurance and partially from assets of the Sponsor	A - Active F - Frozen M - Merged T - Terminated S - Sold (Spun-off) If any plan has been merged, terminated or sold, indicate date of transaction.

1. Full Plan Name	2. Plan Type	3. Report Year	4. Fund Status	5. Asset Value (000)	6. Annual Contributions	7. No. of Participants	8. Plan Status

* List any additional plans on a separate attachment

Total assets of all plans to be covered under this policy:
$

Total number of plan trustees and other employees who act in a fiduciary capacity

Plan Underwriting Questions

1. Has the IRS withdrawn or threatened to withdraw the tax exempt status of any plan?
Yes No

If Yes, explain.

2. Has any plan experienced an event report-able to the PBGC within the past three years?
Yes No

If Yes, explain.

3. Has any plan been the subject of an investigation by the DOL, IRS or similar foreign regulatory agency in the last three years ?
Yes No

If Yes, explain.

4. Does the plan(s) conform to the standards of eligibility, participation, vesting and other provisions of ERISA or similar foreign law?
Yes No

If No, explain.

5. Has any plan filed for exemption from a prohibited transaction? If Yes, attach copy of filing and DOL response.
Yes No

6. Has an actuary certified that the plans are adequately funded in accordance with ERISA’s minimum funding standard?
Yes No

If No, explain.

7. Is each plan reviewed periodically to assure there are no violations of prohibited transactions or party-in-interest rules of ERISA?
Yes No

If No, explain.

8. Has any plan received an adverse opinion as to its financial condition by an independent public accountant?
Yes No

If Yes, attach copy of plan audit.

9. Does any plan hold employer securities or employer real property in violation of ERISA or in excess of ERISA limits?
Yes No

If Yes, explain.

10. Is any plan loan, lease or debt obligation in default or classified as uncollectible?
Yes No

If Yes, explain.

11. Are there any outstanding delinquent plan contributions?
Yes No

If Yes, explain.

12. Does any plan invest in or provide an option to invest in employer securities?
Yes No

If Yes, explain.

13. In the past two years have there been any plan amendments or do you anticipate any plan amendments that will result in a reduction in benefits?
Yes No

If Yes, explain.

14. Has any plan been merged with another plan, terminated or sold within the past two years or are any anticipated to be merged, terminated or sold in the next 12 months?
Yes No

If Yes, explain.

15. If any plan has been terminated, were benefits secured with the purchase of annuities?
Yes No

If Yes, please provide the name of the insurance carrier(s).

16. Does the employer, committee of employer representatives, or union board of trustees have final say over the determination of whether benefits will be paid under any health and welfare plan sponsored by this Insured?
Yes No

INVESTMENT ADVISORS

Please list all outside professional investment advisor(s) utilized by the plan(s) listed on page 2.

If any plan does not utilize outside professional investment advisor(s), please attach a schedule of each plan's investments.

CURRENT INSURANCE COVERAGES

Policy	Limit	Deductible	Insurance Co.	Eff. Date	Premium
Directors & Officers
Errors & Omissions
Employment Practices
Fidelity/Crime
Workers Comp.
Commercial GL

List locations of all resident employees and the number of employees at each
(more than 6 months, please attach separate page if necessary.)

Country	TOTAL #

List anticipated foreign travel by specific country and number of employees
(more than 6 months, please attach separate page if necessary.)

SPECIFIC COUNTRY	# OF EMPLOYEES

REQUIRED ATTACHMENTS

For Single Employer Plans or Controlled Groups of Corporations:

• Coverage limit requests of $1,000,000 or greater attach:

Sponsor financial statements,
Form 5500’s for each pension plan with attached schedules A, B, C, E (ESOP) & G as applicable, and
Plan financial statements for each pension plan.

Information requests may vary from the above based on specific account or industry characteristics.

The undersigned declares that the statements set herein are true to the best of his or her knowledge and belief. The undersigned agrees that this application and attachments form the basis of the contract should a policy be issued and shall be deemed attached to and form part of a policy. The Company is hereby authorized to make any investigation and inquiry in connection with this application.

Attention: Insureds in KY
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.

Signed by Trustee/Fiduciary:	Dated:
Print Name:	Title:

FRAUD WARNINGS

Attention: Insureds in AR, FL, KY, ME, MN, NJ, OH, and PA
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.

Attention: Insureds in DC:
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.

Attention: Insureds in NY
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.

Attention: Insureds in CO
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 TN and VA
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 LA and NM
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.

Attention: Insureds in OK
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.

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