APPLICATION FOR
PENSION ACTUARIES, PENSION and BENEFIT ADMINISTRATORS & CONSULTANTS
COMBINED PROFESSIONAL LIABILITY INSURANCE
THIS APPLICATION IS FOR A
“CLAIMS MADE” INSURANCE POLICY
THIS PROFESSIONAL LIABILITY COVERAGE IS PROVIDED ON A CLAIMS-MADE BASIS; THEREFORE, THIS POLICY PROVIDES NO COVERAGE FOR CLAIMS ARISING OUT OF WRONGFUL ACTS WHICH TOOK PLACE PRIOR TO THE RETROACTIVE DATE STATED IN THE POLICY. SUBJECT TO ITS TERMS, THIS POLICY WILL APPLY ONLY TO CLAIMS ACTUALLY MADE OR INCIDENTS REPORTED AGAINST YOU WHILE THE POLICY REMAINS IN EFFECT. DURING THE FIRST SEVERAL YEARS OF THE CLAIMS-MADE RELATIONSHIP, CLAIMS–MADE RATES ARE COMPARATIVELY LOWER THAN OCCURRENCE RATES. YOU CAN EXPECT SUBSTANTIAL ANNUAL PREMIUM INCREASES, INDEPENDENT OF OVERALL RATE LEVEL INCREASES, UNTIL THE CLAIMS-MADE RELATIONSHIP REACHES MATURITY.
APPLICANT’S INSTRUCTIONS
- ALL QUESTIONS MUST BE ANSWERED COMPLETELY. PLEASE TYPE OR PRINT CLEARLY. IF ANY QUESTIONS ARE CONSIDERED “NOT APPLICABLE”, PLEASE EXPLAIN WHY.
- PLEASE USE THE COMMENTS LINE(S) FOR ADDITIONAL INFORMATION OR CONTINUE ON A SEPARATE ADDENDUM INDICATING THE QUESTION NUMBER.
1. / Name of Applicant:
Individual Partnership Professional Corporation Other:
Address:
City: / County:
State: / Zip Code:
Telephone Number: / Fax Number:
Website Address:
2. / Date firm was established:
- Indicate the professional associations relating to the services to be insured, in which the Applicant Firm (or any officer, or employee) belong:
ASPPACCA SOA NIPA IFEBP Other (please specify)
- Please state your Total Gross Revenue, whether collected or not, by Fiscal Year:
Fiscal Year: / (mm/dd/yyyy)
Current Fiscal Year / 20 / $ / Last Fiscal Year / 20 / $
Projected for coming Year / 20 / $ / $
5.A.Is the Applicant firm controlled, owned or associated with any other firm, corporation or company? Yes No
If yes, attach an explanation.
B.Are any activities listed in 6 below provided to such an affiliated enterprise? Yes No
If yes, attach an explanation.
6.For what types of claims/exposures do you require coverage and what safeguards/procedures do you employ to avoid such losses?
7.Briefly describe your three largest clients by fee income during the past year:
Client Type / Nature of Services Performed for Client / Revenues$
$
$
8.Please indicate the Percentage and Total Gross Revenue derived from the following activities: (OVERALL TOTAL MUST EQUAL 100%)
(Based on Recently Completed Fiscal Year)
Professional Services / Percentage / Total Gross Receiptsa) / Pension & Welfare Administrative work by type of plans (i.e. Defined Benefit)
Defined Benefit Plans / $
Defined Contribution Plans / $
Health/Benefit Plans / $
Other: / $
b) / Pension & Welfare Fund Consulting / $
c) / Sales and Services of Group Medical Plans and Life Insurance (including Variable) / $
d) / Actuarial Services / $
e) / 3(16) Fiduciary Plan Administrator: List number of plans – () / $
f) / Insurance/Management Consulting / $
g) / Other
$
$
Total / 100% / $
9.Please indicate the number of plans and approximate fees/gross revenue generated by plans for the following categories of clients.
EST. # of Plans / Approximate Fees/Gross RevenueUnions / $
Attorneys / Law Firms / $
Physicians / Dentists / Medical Groups / $
10.Does the Applicant require a written contract or agreement for services with clients? Yes No
If yes, do such contracts contain: (check all that apply) Please attach a sample contract.
Hold harmless or indemnity agreements inuring to your benefit? Guarantees or warranties?
Hold harmless or indemnity agreements inuring to your clients benefit? A specific description of the services you will provide?
11.Have you received the CEFEX ASPPA Administration Services Certification? Yes No
12.Do you utilize the PensionPro Workflow System software? Yes No
13.Do you administer any 412(i) plans (also known as 412(e) plans), now or within the last Yes No
five years, for any of your customers?
If yes, approximately what amount of your revenue is derived from administering these types of plans? %
14.EMPLOYMENT
Number of StaffThis Year / Last Year
Partners/Principals/Officers
Enrolled Actuaries
Technical/Professional Employees
Other Staff
Total:
Please list the name of all Owners, Partners, Directors, Officers and employed Actuaries: (Attach separate sheet if needed)
Name / Title / Year inPractice / Enrolled
Yes/No / Professional
Organization
15.Please provide the following information for similar insurance, if any, carried during the last five years. (Professional Liability / E&O)
Company / Period / Limit / Deductible / PremiumB.Has any application for similar insurance made on behalf of the applicant or any of its predecessors in business or present partners, owners, officers, sales personnel or employees ever been cancelled or renewal refused? Yes No
If yes, please attach explanation.
16.Please state coverage Limits and Deductibles requested for Professional Liability Insurance:
Limit Requested: / $ / Each Claim / $ / AggregateDeductible Requested: / $ / Each Claim
Retroactive (Prior Acts) Date Requested:
(mm/dd/year)
Warranties
17. Does any person to be insured have knowledge or information of any act, error or omission (including fee disputes) which might reasonably be expected to give rise to a claim against him? (“CLAIM” shall mean a demand received by the Insured for money or service, including Service of Suit or institution of arbitration proceedings against the Insured.) Yes No
18. Please provide the status and details of all errors and omissions claims against any proposed insured(s) during the past five (5) years.
If none, please check here: NONE
YEAR / NUMBER OF CLAIMS / PAID / RESERVED / Please attach details of all paid and reserved claims.$ / $
$ / $
$ / $
$ / $
$ / $
19. Has the applicant or any of its predecessors in business or subsidiaries or affiliates or any of the past or present partners, owners,
officers, sales personnel or employees been investigated and/or cited by any regulatory agency for violations arising out of their
professional activities?
Yes No
If yes to any of the above, please provide details.
The applicant acknowledges that any claims or incidents reported in, or that should have been reported in, this section will be excluded from coverage.
The Applicant declares and warrants that, after enquiry, to the best knowledge of all persons to be insured the statements set forth herein and in any attachments made hereto are true and no material facts have been suppressed omitted or misstated. Underwriters reserve the right to deny or rescind coverage on any Policy that is issued as a result of this Application if, in the statements set forth herein and in any attachments made hereto it is found that material information has been omitted, suppressed or misstated. Underwriters also reserve the right to amend the terms, conditions and limitations, coverage of any Policy that is issued as a result of this application, if subsequent to the date of this application, but prior to the inception date of such policy, there are any material alterations to the information contained herein. In the event of such material alteration, as aforesaid, the Applicant agrees to give written notice to Underwriters as soon as practicable and such notice shall attach to and form part of this application. Signing this application does not bind the Applicant or Underwriters to complete the Insurance, but it is agreed that the statements and particulars contained herein will be relied upon by underwriters should a Policy be issued. This application is signed on behalf of all Owners, Partners, Shareholders and Corporate Officers.
AUTHORIZED SIGNATURE OF APPLICANTMust be a principal of the Applicant and a person at risk / TITLE
Date / Effective Date Requested for this Insurance
NOTICE TO ARIZONA AND MISSOURI APPLICANTS: CLAIM EXPENSES ARE INSIDE THE POLICY LIMITS. ALL CLAIM EXPENSES SHALL FIRST BE SUBTRACTED FROM THE LIMIT OF LIABILITY, WITH THE REMAINDER, IF ANY, BEING THE AMOUNT AVAILABLE TO PAY FOR DAMAGES.
NOTICE TO ARKANSAS, LOUISIANA AND WEST VIRGINIA 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 FINES AND CONFINEMENT IN PRISON.
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 PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICY HOLDER 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.
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 FLORIDA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE.
NOTICE TO HAWAII APPLICANTS: FOR YOUR PROTECTION, HAWAII LAW REQUIRES YOU TO BE INFORMED THAT PRESENTING A FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT IS A CRIME PUNISHABLE BY FINES OR IMPRISONMENT, OR BOTH.
NOTICE TO IDAHO AND 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 KENTUCKY 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.
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 INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS.
NOTICE TO MARYLAND APPLICANTS: ANY PERSON WHO KNOWINGLY AND WILLFULLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY AND WILLFULLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.
NOTICE TO MICHIGAN AND MINNESOTA 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, IS GUILTY OF A FELONY AND IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.
NOTICE TO NEW JERSEY APPLICANTS: ANY PERSON WHO KNOWINGLY INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE POLICY OR FILES A STATEMENT OF CLAIM CONTAINING ANY FALSE OR MISLEADING INFORMATION IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.
NOTICE TO NEW MEXICO AND RHODE ISLAND 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 OHIO APPLICANTS: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE 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.
NOTICE TO OREGON APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD OR SOLICIT ANOTHER TO DEFRAUD ANY INSURANCE COMPANY: (1) BY SUBMITTING AN APPLICATION, OR (2) BY FILING A CLAIM CONTAINING A FALSE STATEMENT AS TO ANY MATERIAL FACT, MAY BE VIOLATING STATE 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 VERMONT APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE STATEMENT IN AN APPLICATION FOR INSURANCE MAY BE GUILTY OF A CRIMINAL OFFENSE AND SUBJECT TO PENALTIES UNDER STATE LAW.
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