Form C24393 – Fill Out and Use This PDF

Executive Risk Indemnity Inc.	Administrative Offices/Mailing Address:
Home Office	82 Hopmeadow Street
Dover, Delaware 19901	Simsbury, Connecticut 06070-7683

RENEWAL APPLICATION

PENSION AND WELFARE BENEFIT PLAN 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” OR ANY APPLICABLE EXTENDED REPORTING PERIOD. THE POLICY PROVIDES THAT THE LIMIT OF LIABILITY AVAILABLE TO PAY JUDGMENTS OR SETTLEMENTS SHALL BE REDUCED BY “DEFENSE EXPENSES,” AND THAT “DEFENSE EXPENSES” SHALL BE APPLIED AGAINST THE RETENTION.

1.a) Name of Sponsor Organization: ____________________________________________________________

b)Principal Address: _______________________________________________________________________

City: ___________________________________________ State: ______________ ZIP: _____________

c)Name and title of the officer of the Sponsor Organization who will be the Insurance Representative designated as the exclusive agent to act on behalf of the Insureds, individually or collectively, in all matters relating to this insurance: __________________________________________________________

______________________________________________________________________________________

2. Will funds from the Plan be used to purchase insurance?				o Yes	o No
If “Yes,” is it understood that the Employee Retirement Income Security Act of 1974 (“ERISA”),
as amended, allows the Insurer to seek recourse against Insureds under certain circumstances,
and that the insurance policy herein applied for will contain such a recourse provision?				o Yes	o No
3. Complete the following for all Plans. Attach a schedule, if necessary.
Under Status, insert the appropriate letter:		Under Type, insert the appropriate number:
A.	Benefits exclusively from insurance or annuity	1.	Defined Benefit
	contracts	2.	Defined Contribution
B.	Investments by bank or trust company	3.	Welfare
C.	Investment Manager appointed (ERISA 402(c)(3))	4.	Other (specify)
D.	Investments under Plan or sponsor control

PLEASE ATTACH LATEST FORM 5500, INCLUDING ALL APPLICABLE SCHEDULES, AND CURRENT AUDITED FINANCIAL STATEMENTS FOR EACH PLAN AND THE SPONSOR ORGANIZATION.

Form C24393 (4/97 ed.)

1

Catalog No. FIDra-I

Form 14-03-0274

4.If any Plan listed in the schedule in Question 3 is an Employee Stock Ownership Plan, please fill in the following. Otherwise, proceed to Question 5.

a)Plan name: ____________________________________________________________________________

b)When was the Plan established? ___________________________________________________________

c)What percentage of the Sponsor Organization’s common stock is held by the Plan? __________________

d)If the stock is not publicly traded on an exchange, how is the stock valued? _________________________

e)How often is the stock valued? _____________________________________________________________

5.If any benefits are from insurance/annuity contracts, please fill in the following. Otherwise, proceed to Question 6.

a)Plan name: _______________________ Insurance carrier: ______________________________________

b)Plan name: _______________________ Insurance carrier: ______________________________________

6.Have procedures been adopted to ensure that each Plan is administered according to its terms, and that it complies in form and operation with ERISA, the Internal Revenue Code of 1986,

and other applicable laws and regulations?

o Yes o No

7. Please answer the following questions, and explain by attachment to this Application any “Yes” answer.

a) Has any Plan filed for exemption from a prohibited transaction?	o Yes	o No
b) Does any Defined Benefit Pension Plan have a funding deficiency?	o Yes	o No
c) Has the Internal Revenue Service withdrawn or threatened to withdraw the tax-exempt
status of any Plan?	o Yes	o No
d) Does any Plan hold employer securities or employer real property in violation of ERISA or
in excess of amounts permitted by ERISA?	o Yes	o No
e) Is any Plan loan, lease or debt obligation in default or classified as uncollectible?	o Yes	o No

f)Has any Plan received an adverse opinion as to its financial condition by an independent

public accountant?	o Yes	o No
g) Has any person acting as a fiduciary of any Plan been:
i) accused or found guilty of a breach of trust?	o Yes	o No
ii) accused or found guilty under any criminal act enumerated in Section 411 of ERISA?	o Yes	o No
iii) refused coverage under a fidelity bond?	o Yes	o No
8. a) In the past twelve (12) months has a merger, transfer of assets or termination of a Plan
(or Plans) been completed or agreed to?	o Yes	o No
If “Yes,” please explain: __________________________________________________________________
______________________________________________________________________________________
b) Is any merger, transfer of assets or termination of a Plan (or Plans) expected within the
next twelve (12) months?	o Yes	o No

If “Yes,” please explain: __________________________________________________________________

______________________________________________________________________________________

9.Does the Sponsor Organization have a financial, equity or other interest in any outside consultant (i.e., investment advisor, actuary, legal counsel, CPA, Administrator, etc.) or is any

such consultant a director, officer and/or employee of the Sponsor Organization?o Yes o No If “Yes,” please explain: ______________________________________________________________________

_________________________________________________________________________________________

Form C24393 (4/97 ed.)

2

Catalog No. FIDra-I

Form 14-03-0274

NOTICE TO APPLICANT ¾ PLEASE READ CAREFULLY.

FOR THE PURPOSE OF 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/HER KNOWLEDGE AND BELIEF, AFTER REASONABLE INQUIRY, THE STATEMENTS HEREIN ARE TRUE AND COMPLETE. THE UNDERWRITER IS AUTHORIZED TO MAKE ANY INQUIRY IN CONNECTION WITH THIS RENEWAL APPLICATION. ACCEPTING THIS RENEWAL APPLICATION DOES NOT BIND THE UNDERWRITER TO COMPLETE THE INSURANCE.

THE INFORMATION CONTAINED IN AND SUBMITTED WITH THIS RENEWAL APPLICATION IS ON FILE WITH THE UNDERWRITER AND ALONG WITH THE RENEWAL APPLICATION IS CONSIDERED PHYSICALLY ATTACHED TO THE POLICY. THE UNDERWRITER WILL HAVE RELIED UPON THIS RENEWAL APPLICATION AND ATTACHMENTS IN ISSUING ANY POLICY. THIS RENEWAL APPLICATION WILL BECOME A PART OF SUCH POLICY IF ISSUED.

IF THE INFORMATION IN THIS RENEWAL APPLICATION MATERIALLY CHANGES PRIOR TO THE EFFECTIVE DATE OF THE POLICY, THE APPLICANT WILL NOTIFY THE UNDERWRITER, WHO MAY MODIFY OR WITHDRAW ANY QUOTATION.

THE UNDERSIGNED DECLARES THAT THE PERSON(S) OR ENTITY(IES) PROPOSED FOR THIS INSURANCE UNDERSTAND THAT:

(I)THIS POLICY APPLIES ONLY TO “CLAIMS” FIRST MADE DURING THE “POLICY PERIOD” OR, IF PURCHASED, ANY EXTENDED REPORTING PERIOD.

(II)THE LIMIT OF LIABILITY AVAILABLE TO PAY DAMAGES OR SETTLEMENTS WILL BE REDUCED BY “DEFENSE EXPENSES,” AND “DEFENSE EXPENSES” WILL BE APPLIED AGAINST THE RETENTION.

NOTICE TO ARKANSAS, MINNESOTA, 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 OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD, WHICH IS A CRIME.

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 FLORIDA 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 OR AN APPLICATION CONTAINING ANY FALSE OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE.

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 FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.

NOTICE TO MAINE AND 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 MAY INCLUDE IMPRISONMENT, FINES, OR A DENIAL OF INSURANCE BENEFITS.

NOTICE TO MARYLAND 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 MAY BE GUILTY OF INSURANCE FRAUD.

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.

Form C24393 (4/97 ed.)

3

Catalog No. FIDra-I

Form 14-03-0274

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 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.

NOTICE TO OKLAHOMA APPLICANTS: 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.

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.

SPONSOR ORGANIZATION

NOTE: This Renewal Application must be signed by the Insurance Representative of the Sponsor Organization acting as the authorized agent of the person(s) and entity(ies) proposed for this insurance.

PRODUCED BY (Insurance Agent)	INSURANCE AGENCY
INSURANCE AGENCY TAXPAYER ID OR SOCIAL SECURITY	AGENT LICENSE NO.
NO.
ADDRESS (No., Street, City, State, and ZIP Code)
EMAIL ADDRESS

ADDRESS (No., Street, City, State, and ZIP Code)

Form C24393 (4/97 ed.)

4

Catalog No. FIDra-I

Form 14-03-0274