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UNDERWRITING INFORMATION |
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Fiduciary Liability Limit Request |
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Fiduciary Liability Policy Period Request Start |
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Fiduciary Liability Policy Period Request Start |
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| Do
you want to include all subsidiaries? |
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Subsidiaries to be Covered |
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For each
sub to be included, provide: Name, Nature of
Business, Percentage Owned, Date Acquired/Created
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| Does
the parent organization, a subsidiary or any
director or officer currently act in the capacity of
general partner in a limited or general
partnership? |
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If yes,
briefly describe, otherwise enter NO
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| Are
plan benefits provided by insurance (e.g. annuity,
medical policy, etc.)? |
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If yes,
state the name of the insurance company, otherwise
enter NO
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| Size
of Plans (All Plans Combined) |
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| Have
there been any mergers of plans in the past 3
years? |
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If yes,
please describe, otherwise enter NO
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| Have
there been any plan terminations in the past 3
years? |
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If yes,
please describe, otherwise enter NO
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| Were
benefits from terminated plans secured by the
purchase of annuities? |
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If yes,
please describe and list annuity carrier, otherwise
enter NO
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| Do
the plans conform to the standards of eligibility,
participation, vesting, funding and other provisions
of ERISA? |
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If no,
please explain, otherwise enter YES
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| Have
the plans been reviewed to assure that there are no
violations of prohibited transactions and
party-in-interest rules? |
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If no,
please explain, otherwise enter YES
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| Has
an actuary certified that the plans are adequately
funded? |
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If no,
please explain, otherwise enter YES
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| Are
there any outstanding delinquent contributions? |
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If yes,
please describe briefly, otherwise enter NO
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| Have
any plans experienced any event reportable to the
PBGC? |
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If yes,
briefly describe, otherwise enter NO
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| Has
any fiduciary been accused, found guilty or held
liable for a breach of trust? |
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If yes,
briefly describe, otherwise enter NO
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| Has
any fiduciary been convicted of criminal conduct? |
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If yes,
briefly describe, otherwise enter NO
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| Have
any claims (other than for benefits) been made
during the past 5 years against any benefit program
or any current or past fiduciaries? |
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If yes,
briefly describe, otherwise enter NO
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| Does
the parent organization currently have Fiduciary
Liability insurance? If yes, please provide the
following, otherwise enter N/A. |
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| Has
the parent organization, a subsidiary or any insured
person given written notice under the provisions of
any prior or current employment practices liability
or similar insurance of specific facts or
circumstances which might give rise to a claim being
made against any insured? |
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If
yes, briefly describe, otherwise enter NO
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| Have
any loss payments been made on behalf of any insured
under any fiduciary liability policy or similar
insurance? |
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If
yes, briefly describe, otherwise enter NO
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Continuity of coverage:
If the insured organization currently has coverage,
does it wish to request continuity of coverage? |
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If yes, enter Continuity
Date requested, otherwise enter N/A
If yes, we will require a copy of the prior
application with which continuity of coverage is
to be maintained. The declarations and
statements contained in such prior application
shall be considered to be incorporated in and
form a part of the policy. |
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No continuity of coverage:
If the insured organization has not had previous
coverage or has requested coverage and been denied,
please complete the following: |
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"No person proposed for
coverage is aware of any facts or circumstances
which he or she has reason to suppose might give
rise to a future claim that would fall within
the scope of the proposed coverage, except:"
(if there are no exceptions, please state,
otherwise enter the exceptions below)
It is agreed that if such facts or circumstances
exist, whether or not disclosed, any claim or
action arising from them is excluded from this
proposed coverage. |
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