Form 14 03 0852 PDF Details

The 14 03 0852 form serves as a pivotal document for organizations seeking to secure a Fiduciary Fidelity Bond under the ERISA (Employee Retirement Income Security Act of 1974). Prepared by the Chubb Group of Insurance Companies, this form is a cornerstone for renewing coverage that safeguards employee benefits plans from fraudulent activities or dishonest actions by fiduciaries or employees. It is crucial for applicants, who are the fiduciaries of the employee benefit plans, to provide comprehensive and accurate information throughout the application process. This information not only includes general details about the applicant but extends to financial statements, a summary of plans, external audits, and an overview of any material changes in operations or compliance issues within the last year. The form also emphasizes the importance of honesty, highlighting that any deliberate misrepresentation or concealment of material facts can lead to the rescission of the bond. Additionally, it includes fraud warnings specific to different states, underscoring the legal ramifications of submitting false information. This renewal application plays a vital role in ensuring compliance with federal regulations and in offering protection to both plans and their participants, making it an essential process for maintaining the integrity and financial security of employee benefits plans.

QuestionAnswer
Form NameForm 14 03 0852
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other nameschubb8019 chubb erisa bond insurance form

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Chubb Group of Insurance Companies

FIDUCIARY FIDELITY BOND

15 MOUNTAIN VIEW ROAD

FOR EMPLOYEE BENEFITS PLAN

Warren, New Jersey 07059

(ERISA BOND) RENEWAL APPLICATION

 

 

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:

City:

 

State:

 

Zip Code:

 

Telephone:

3.Web address:

4.Name and Address of Primary Contact:

City:

 

State:

 

Zip Code:

 

Telephone:

 

e-Mail:

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.)

14-03-0852 (12/2007)

Page 1 of 4

Chubb Group of Insurance Companies

FIDUCIARY FIDELITY BOND

15 MOUNTAIN VIEW ROAD

FOR EMPLOYEE BENEFITS PLAN

Warren, New Jersey 07059

(ERISA BOND) RENEWAL APPLICATION

 

 

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

account activities?

o Yes o No

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

audit?

o Yes o No

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

(12) months?

o Yes o No

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)

months?

o Yes o No

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.

14-03-0852 (12/2007)

Page 2 of 4

Chubb Group of Insurance Companies

FIDUCIARY FIDELITY BOND

15 MOUNTAIN VIEW ROAD

FOR EMPLOYEE BENEFITS PLAN

Warren, New Jersey 07059

(ERISA BOND) RENEWAL APPLICATION

 

 

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.

14-03-0852 (12/2007)

Page 3 of 4

Chubb Group of Insurance Companies

FIDUCIARY FIDELITY BOND

15 MOUNTAIN VIEW ROAD

FOR EMPLOYEE BENEFITS PLAN

Warren, New Jersey 07059

(ERISA BOND) RENEWAL APPLICATION

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

Date

 

Name (PRINT)

 

Signature*

 

Title

 

 

 

 

 

 

 

Produced By: Agent:

 

Agency:

 

 

Agency Taxpayer ID or SS No.:

 

Agent License No.:

 

 

Address (Street, City, State, Zip):

 

 

 

 

 

Submitted By: Agency:

 

 

 

 

 

Agency Taxpayer ID or SS No.:

 

Agent License No.:

 

 

Address (Street, City, State, Zip):

 

 

 

 

 

 

 

 

 

 

 

 

 

14-03-0852 (12/2007)

Page 4 of 4

How to Edit Form 14 03 0852 Online for Free

The Form 14 03 0852 filling in procedure is hassle-free. Our editor allows you to work with any PDF file.

Step 1: Choose the button "Get form here" to access it.

Step 2: Now you should be on the document edit page. You can include, change, highlight, check, cross, add or erase fields or phrases.

For each section, add the content required by the application.

filling in Form 14 03 0852 part 1

Include the expected details in the Chubb Group of Insurance Companies, FIDUCIARY FIDELITY BOND FOR, Summary of Schedule in c above, Number of Plans to be covered, Total required aggregate Limit of, The Total required aggregate Limit, With respect to External Audits, Does the CPA regularly review your, o Yes o No, Has the Applicant complied with, o Yes o No, If No provide a schedule, and Has the Applicant made any box.

step 2 to filling out Form 14 03 0852

It is crucial to record certain information inside the section If Yes attach an explanation, III MATERIAL CHANGE, If there is any material change in, IV DECLARATIONS FRAUD WARNINGS AND, The Applicants submission of this, The undersigned authorized agent, and Page of.

Filling in Form 14 03 0852 stage 3

Inside of space Chubb Group of Insurance Companies, FIDUCIARY FIDELITY BOND FOR, The information requested in this, Notice to Arkansas Louisiana, Notice to Colorado Applicants It, Notice to District of Columbia, Notice to Maine Tennessee Virginia, and Notice to Florida and Oklahoma, define the rights and responsibilities.

Finishing Form 14 03 0852 stage 4

End by looking at all of these areas and writing the required details: Chubb Group of Insurance Companies, FIDUCIARY FIDELITY BOND FOR, This Renewal Application must be, Date, Name PRINT, Signature, Title, Produced By Agent, Agency, Agency Taxpayer ID or SS No, Agent License No, Address Street City State Zip, Submitted By Agency, Agency Taxpayer ID or SS No, and Agent License No.

Filling out Form 14 03 0852 part 5

Step 3: As soon as you are done, choose the "Done" button to export your PDF form.

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