Form 14 03 0852 – Fill Out and Use This PDF

BY COMPLETING THIS RENEWAL APPLICATION YOU ARE APPLYING FOR COVERAGE WITH FEDERAL INSURANCE COMPANY OR VIGILANT INSURANCE COMPANY (THE “COMPANY”)

NOTICE: PLEASE ANSWER ALL OF THE FOLLOWING INQUIRIES. IF THE COMPANY AGREES TO ISSUE A BOND, ALL OF THE INFORMATION WHICH THE APPLICANT PROVIDES WILL BECOME PART OF ANY BOND ISSUED TO THE APPLICANT BY FEDERAL INSURANCE COMPANY OR VIGILANT INSURANCE COMPANY. ANY INTENTIONAL MISREPRESENTATION, OMISSION, CONCEALMENT OR INCORRECT STATEMENT OF MATERIAL FACT IN THIS RENEWAL APPLICATION WILL BE GROUNDS FOR RECISION.

EXCEPT AS TO THE AMOUNT REQUIRED, THE FIDUCIARY FIDELITY BOND FOR EMPLOYEE BENEFITS PLAN PROVIDES PROTECTION TO THE ASSURED PLAN AS REQUIRED BY SECTION 412 OF THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974 (“ERISA”), BUT ONLY AS RESPECTS ANY EMPLOYEE OF THE FIDUCIARY NAMED HEREIN. READ THE ENTIRE RENEWAL APPLICATION CAREFULLY BEFORE SIGNING.

RENEWAL APPLICATION INSTRUCTIONS:

1.Whenever used in this Renewal Application, the term "Applicant" shall mean the Fiduciary of the Employee Benefit Plans to be covered (hereinafter “Plans”).

2.Please include all requested underwriting information and attachments. Provide a complete response to all questions and attach additional pages if necessary.

I.NAME, ADDRESS AND CONTACT INFORMATION:

1.Name of Applicant:

2.Address of Applicant:

3.Web address:

4.Name and Address of Primary Contact:

II.GENERAL APPLICANT INFORMATION:

1.Year Applicant established:

2.Nature of Applicant’s operations:

3.Please attach a copy of the following:

a.Most recent FYE Financial Statement of the Applicant.

b.Most recent CPA Letter of Recommendation to Management on Internal Controls regarding your ERISA Plan account activities, and Management’s written response thereto.

c.A complete schedule of all Plans for which the Applicant acts as a fiduciary and is requesting coverage. Please include the name of each Plan and the respective assets of each Plan. Also identify each Plan that holds employer securities. (The term “employer security”, within the meaning of section 407(d)(1) of ERISA, means a security issued by an employer of employees covered by the plan, or by an affiliate of such employer.)

4.Summary of Schedule in 3.c. above:

a.Number of Plans to be covered:

b.“Total required aggregate Limit of Liability” for all Plans:

(The “Total required aggregate Limit of Liability” equals the sum of the required Bond amounts for all Plans. As per section 412 of ERISA, the required Bond amount of limit of liability for each Plan shall not be less than 10% of the assets of the Plan and in no case shall the limit of liability for a specific Plan be less than $1,000 but no more than $500,000. However, the Pension Protection Act of 2006 requires a maximum amount of $1,000,000 for any Plan that holds employer securities.)

5.With respect to External Audits:

a.Does the CPA regularly review your system of internal controls regarding your ERISA Plan

b.Has the Applicant complied with all recommendations made as a result of its most recent

If “No”, provide a schedule explaining any noncompliance with such recommendations.

6.Has the Applicant made any material changes in its operations including, but not limited to, corporate structure or bylaws, internal controls, or audit procedures during the previous twelve

If “Yes”, attach an explanation.

7.Has the Applicant entered into, been operating under, or been advised of a regulatory agency’s intent to issue any consent agreements, special situation agreements, memoranda of understanding, cease and desist orders, or similar restrictions during the previous twelve (12)

If “Yes”, attach an explanation.

III.MATERIAL CHANGE:

If there is any material change in the answers to the questions in this Renewal Application before the bond inception date, the Applicant must immediately notify the Company in writing, and any outstanding quotation may be modified or withdrawn.

IV. DECLARATIONS, FRAUD WARNINGS AND SIGNATURES:

The Applicant's submission of this Renewal Application does not obligate the Company to issue, or the Applicant to purchase, a bond. The Applicant will be advised if the Renewal Application for coverage is accepted. The Applicant hereby authorizes the Company to make any inquiry in connection with this Renewal Application.

The undersigned authorized agent of the person(s) and entity(ies) proposed for this insurance declares, that to the best of his or her knowledge and belief, after reasonable inquiry, the statements made in this Renewal Application and in any attachments or other documents submitted with this Renewal Application are true and complete. The undersigned agrees that this Renewal Application and such attachments and other documents shall be the basis of the insurance should a bond providing the requested coverage be issued; that all such materials shall be deemed to be attached to and shall form a part of any such bond; and that the Company will have relied on all such materials in issuing any such bond.

The information requested in this Renewal Application is for underwriting purposes only and does not constitute notice to the Company under any policy of a claim or potential claim.

Notice to Arkansas, Louisiana, Maryland, Minnesota, New Mexico and 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, fraudulent or deceptive statement is, or may be found to be, guilty of insurance fraud, which is a crime, and may be subject to civil fines and criminal penalties.

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 policy holder 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.

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 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 a denial of insurance benefits.

Notice to Florida and Oklahoma Applicants: Any person who, knowingly and with intent to injure, defraud or deceive any employer or employee, insurance company, or self-insured program, files a statement of claim containing any false or misleading information is guilty of: a felony (in Oklahoma) or a felony of the third degree (in Florida).

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 false information, or conceals for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent insurance act which is a crime.

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 Oregon and Texas Applicants: Any person who makes an intentional misstatement that is material to the risk may be found guilty of insurance fraud by a court of law.

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 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.

*This Renewal Application must be signed by the Officer responsible for ERISA accounts, the Compliance Officer or the General Counsel of the Applicant.