Download - The Guarantee Company of North America

FIDUCIARY SHIELD APPLICATION - FIDUCIARY LIABILITY INSURANCE
ATTACH TO THIS APPLICATION THE MOST RECENT:
a)
b)
c)
AUDITED FINANCIAL STATEMENT OF THE SPONSOR ORGANISATION;
AUDITED FINANCIAL STATEMENT OF EACH PENSION PLAN;
ACTUARIAL REPORT OF EACH PENSION PLAN;
Words and expressions appearing in bold print are defined in the policy wording.
SPONSOR ORGANISATION:
ADDRESS:
(No.)
(Street)
(City)
(Province)
Phone:
(Postal Code)
Fax:
Web Address:
NATURE OF SPONSOR ORGANISATION'S BUSINESS:
POLICY PERIOD REQUESTED:
From 12:01 am on
LIMIT OF LIABILITY REQUESTED:
$
to 12:01 am on
in the aggregate during the Policy Period.
(actual amount provided may be different than requested)
1.
Please complete the following chart for each Benefit Program to be covered (Please attach separate addendum if space provided below is
insufficient):
NAME OF BENEFIT PROGRAM
TYPE *
YEAR
ESTABLISHED
PLAN ASSETS
ANNUAL CONTRIBUTIONS
$
$
$
$
$
$
$
$
$
$
$
$
# OF PARTICIPANTS
* DB-Defined Benefit Pension Plan DC-Defined Contribution Pension Plan EW-Employee Health & Welfare Plan
2.
Please complete the following, for each Benefit Program listed above, where applicable:
Name/Applicable Benefit Program
(i)
Independent Actuary:
(iii)
Independent Investment Advisor:
(iv)
Administrator:
CR-FSP- 01-001.00.00-00 -E-20140115
Page 1 of 3
Years Employed
Application – Fiduciary Shield
3.
The Benefit Program sponsorship is:
4.
Please indicate which one of the following investment procedures the assets of the pension plan component of the Benefit Program would
fall under:
(i)
(ii)
(iii)
(iv)
Sole
Other (please attach full particulars)
with a financial institution which has full investment discretion?
with investment discretion possessed by a financial institution and in house trustee(s) of the Sponsor Organisation?
with investment discretion processed solely by in house trustee(s) of the Sponsor Organisation?
Other
(please explain):
5.
If the pension plan component of the Benefit Program does not retain an independent investment manager, who makes the investment
decisions?
6.
Are the Benefit Program benefits secured by insurance (e.g. annuity, medical policy, etc)?
Yes
No
Yes
No
If "Yes", state the name of the Insurance Company:
7.
Is the pension plan component of the Benefit Program adequately funded as attested by an Actuary?
If "No", please attach full particulars.
8.
For any Benefit Program which is administered in the United States of America:
(i)
Are the standards of eligibility, participation vesting and funding in compliance with ERISA?
Yes
No
or Not applicable
(ii)
Has the Benefit Program requested exemption from a prohibited transaction?
Yes
No
or Not applicable
(iii)
Is the Benefit Program reviewed periodically by an external independent body to ensure that
there is no violation of prohibited transactions?
Yes
No
or Not applicable
If the answer to any of these questions is "Yes", please attach full particulars.
9.
Has the Canada Revenue Agency (Revenue Canada) withdrawn or threatened to withdraw the tax exempt status of any
component of the Benefit Program?
Yes
No
Yes
No
If "Yes", please explain:
10.
For any pension plan of a Defined Benefit nature, has there been any discussion by the trustee or management
concerning removing surplus funds from the pension plan?
If "Yes", please attach full particulars.
11.
Has any Benefit Program to be covered:
(i)
filed or been considered for termination?
Yes
No
(ii)
ceased to accept new participants or ceased benefit accruals?
Yes
No
(iii)
been involved in a transfer of assets to or from any other Plan?
Yes
No
(iv)
merged or consolidated into another Benefit Program within the past three years?
Yes
No
If the answer to any of these questions is "Yes", please attach full particulars.
12.
Has any Insured Person been:
(i)
found guilty of breach of trust?
Yes
No
(ii)
found guilty of any criminal act?
Yes
No
(iii)
denied coverage under a Fidelity Bond?
Yes
No
Yes
No
If the answer to any of these questions is "Yes", please attach full particulars.
13.
Have any claims (other than for benefits) been made against the Sponsor Organisation, Benefit Program or any of
the current or past Insured Persons, acting in their capacity as a fiduciary or administrator, during the last five years?
If "Yes", please attach full particulars.
14.
Please provide the following details regarding any previous Fiduciary Liability Insurance:
Name of Insurer
Limit of Liability
$
$
$
CR-FSP- 01-001.00.00-00 -E-20140115
Deductible
$
$
$
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Check here if no previous insurance
Period
Premium
$
$
$
Claims
$
$
$
Application – Fiduciary Shield
THE APPLICANT DOES HEREBY PROVIDE THE FOLLOWING WARRANTIES TO THE INSURER:
a)
No claim which would, had insurance similar to that now proposed been in force, have fallen within the scope of such insurance has been
made or is now pending against any person(s) proposed for this insurance, except as follows: (If answer is ''none'', so state)
b)
No person proposed for this insurance is cognizant of any Wrongful Act which s/he has reason to suppose might afford grounds for any
future claim such as would fall within the scope of the proposed insurance, except as follows: (If answer is ''none'', so state))
c)
No similar insurance has been declined or cancelled or renewal thereof refused, except as follows: (If answer is ''none'', so state)
d)
No person who would be an Insured under the proposed insurance policy is aware of any Wrongful Act or allegations thereof, or of any
circumstances which might reasonably be expected to give rise to a claim or allegation of a Wrongful Act, which would fall within the scope
of the proposed insurance policy other than the information disclosed in this Application. It is specifically agreed by all concerned that if
any person(s) who would be Insureds under the proposed insurance policy is aware of any such Wrongful Act or allegation thereof, or of
any such circumstances, any claims subsequently emanating therefrom will be excluded from coverage under the proposed insurance.
e)
The undersigned is duly authorized to make representations and to sign on behalf of the Applicant and declares that the statements herein
are true. Signing of this Application does not bind the Insurer to complete the insurance, but it is agreed that this Application will be the
basis of the contract should a policy be issued, and that this Application will be attached to and become a part of such policy, if issued.
The Insurer is hereby authorized to make any investigation and inquiry in connection with this Application as it may deem necessary.
f)
It is warranted that the particulars and statements contained in the Application for the policy and any materials submitted herewith (which
will be retained on file by the Insurer and which will be deemed attached hereto, as if physically attached hereto), are the basis for the policy
and are to be considered as incorporated into and constituting a part of the policy.
g)
It is agreed that in the event that there is any material change in the answers to the questions contained herein prior to the effective date of
the policy, the applicant will notify the Insurer and, at the sole discretion of the Insurer, any outstanding quotations may be modified or
withdrawn
N.B. COVERAGE CANNOT BE BOUND UNLESS THIS APPLICATION FORM HAS BEEN FULLY COMPLETED AND DULY SIGNED
AND DATED.
Signed and dated this
(Day, Month, Year)
Name and title (please print)
CR-FSP- 01-001.00.00-00 -E-20140115
Signature
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Application – Fiduciary Shield