Fortegra Application for Financial Institutions

FORTEGRA SPECIALTY INSURANCE COMPANY

Application for a Financial Institution Bond, Directors and OfficersLiability/Bankers Professional Liability and/or Kidnap and Ransom Policy
THE PROFESSIONAL LIABILITY COVERAGE PROVIDED BY THE POLICY IS ON A CLAIMS-MADE BASIS. COVERAGE IS LIMITED TO LOSS, INCLUDING DEFENSE EXPENSES RESULTING FROM CLAIMS FIRST MADE AGAINST THE INSURE DURING THE POLICY PERIOD. THERE IS NO COVERAGE UNDER THIS POLICY FOR CLAIMS THAT HAVE BEEN MADE PRIOR TO THE EFFECTIVE DATE LISTED IN ITEM 2. PLEASE READ THE POLICY CAREFULLY.

THE FINANCIAL INSTITUTION BOND COVERAGE AFFORDED UNDER THE POLICY EXTENDS ONLY TO LOSS FIRST DISCOVERED BY THE INSURED DURING THE BOND PERIOD AND REPORTED TO THE UNDERWRITER WITHIN THE PERIOD OF TIME REQUIRED BY THE POLICY. PLEASE READ THE BOND PORTION OF THE POLICY CAREFULLY.

For the purposes of this application, the term applicant means the parent company and all subsidiariesbeing proposed for coverage. Please provide the following information:

Please note:
Input N/A in cells for which you do not have information

You will have an opportunity at the end of this form to upload and describe any additional documents you believe are needed.
Parent Company*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
A. UNDERWRITING INFORMATION:

1. Officer designated as agent of the applicant and of all Directors & Officers to receive any and allnotices and contact from the insurer or its authorized representative, including but not limited to contact regarding any Claims or Losses:
Name*
Title*
E Mail*
example@example.com
Telephone*
Fax
2. Please provide the following current insurance information:
Type of Insurance*
Limit*
Policy Period*
Retention*
Premium*
Insurer*
Have the above coverage(s) been declined, canceled or non-renewed in the past three (3) years?*

YesNo
B. GENERAL INFORMATION
1. FDIC Charter Number*
2. Informational Website Address*
3. Total Number of Employees/Officers*
4. Total Number of Directors and Outside Directors*
5. Number of Full-Service Branches*
6. Number of Safe Deposit Boxes/Number Rented*
7. Number of Off-Premises ATM’s*

D. LOSS AND LITIGATION HISTORY (Prior and Pending):
1. Has any Director or Officer been charged with or convicted of any criminal act or been the subject of a criminal investigation within the past 5 years?*

YesNo
If yes, please provide full details:*
2. Has the applicant sustained any loss in excess of the deductible under its Financial Institution Bond within the past 5 years?*

YesNo
If yes, please provide details including the total amount of loss, the amount recovered from insurance, the name of the insurer and the corrective actions taken:*
3. Have there been during the past 5 years or are there now pending, any oral or written demands for monetary damages or non-monetary relief, civil or criminal proceedings, formal civil administrative or regulatory proceedings against the applicant, or any director, officer, employee or other persons proposed for this insurance?*

YesNo
If yes, please attach details, including the damages sought and current status.*
Please add PartD_Q3 to the start of any file name prior to upload.

Cancelof
It is agreed that any claim related to or arising from these disclosures is/are herein excluded from coverage.

	$
a. armored carrier:
b. designated messenger:
c. employee(s):

I. COVERAGE REQUEST(S):
1. Please provide desired coverage options and advise if different from expiring terms and conditions:

Financial Institution Bond:*

	Yes	No	Limit	Deductible
Agreements A, B, C, E -Trading loss Endorsement?
Agreements D & F - Loan Participation?

	Limit	Deductible
ERISA/Fiduciary Liability Servicing Contractors
Central Handling of Securities
Computer Systems
Extortion (Persons/Property)
Check Kiting
Unauthorized Signatures
FRPM
ATM Endorsement
Claims/Audit Expense
Transit Cash Letters
Safe Deposit Liability
Freddie Mac/FNMA/GNMA

The above limits are a single aggregate limit for all coverage(s).

Professional Liability:

	Limit	Deductible
Director and Officers Liability
Bankers Professional Liability
Employment Practices Liability
Trust E&O
Corporate Fiduciary Liability
Lender Liability
Securities Liability

The above limits are shared as a single limit for all coverage(s).

WARRANTIES AND FRAUD STATEMENT:
Does any Director or Officer of the applicant have knowledge of or know information about any actual or possible loss, act, error, omission which might give rise to a claim under Directors and Officers Liability Coverage, Professional Liability Coverage, Employment Practices Liability Coverage, Lender Liability Coverage, Fiduciary Liability Coverage, a Financial Institution Bond or a Kidnap and Ransom Policy?*

YesNo
If yes, please attach full details:*
Please add Warranty_Fraud to the start of any file name prior to upload.

Cancelof
It is agreed that if such knowledge or information exists, any claims or losses resulting or arising there from are excluded from coverage.
Please attach a copy of the following and add the bracketed title to the start of each file name prior to upload. Check off once you have done so:*

a. [Director_List] A list of all directors and senior officers of the applicant including their principal business affiliations. It is agreed that coverage will not be provided for any business affiliations other than those that are with the applicant.b. [External_Audit, Director_Exam, Internal_Audit] The most recent CPA audit or directors’ exam and/or internal audit.c. [Management_Letter, Management_Responses] The CPA’s management letter on internal controls along with responses to any recommendations made.Check here if a CPA's management letter was not issued.d. [Declaration_Pages, Limits_Requests] The Declaration Pages from the current Financial Institution Bond, D&O and/or Professional Liability Policy, Employment Practices Liability Policy and Kidnap & Ransom Policy and the attached Limits Requests forms.[Supplemental_Information, Subjectivity_Responses] If you need to upload additional documents beyond the ones listed please describe them here:
File Upload*

Cancelof
FRAUD STATEMENT:

NOTICE: IN SOME STATES, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE 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.

FRAUD STATEMENT 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.

FRAUD STATEMENT 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 POLICYHOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO SETTLEMENT OR AWARD PAYABLE FOR INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AGENCIES.

FRAUD STATEMENT 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.

FRAUD STATEMENT 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 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.

FRAUD STATEMENT TO MAINE APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO A INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES, OR A DENIAL OF INSURANCE BENEFITS.

FRAUD STATEMENT TO MARYLAND, OREGON AND RHODE ISLAND APPLICANTS: ANY PERSON WHO KNOWINGLY AND WILLFULLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO 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.

FRAUD STATEMENT 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.

FRAUD STATEMENT 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.

FRAUD STATEMENT 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.

FRAUD STATEMENT 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.

FRAUD STATEMENT TO OKLAHOMA APPLICANTS: WARNING: 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.

FRAUD STATEMENT TO OREGON AND WEST VIRGINIA APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS MATERIALLY FALSE INFORMATION IN AN APPLICATION FOR INSURANCE MAY BE GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.

FRAUD STATEMENT 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.

FRAUD STATEMENT TO 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 INSRANCE BENEFITS.

THE UNDERSIGNED DECLARES THAT THE STATEMENTS SET FORTH HEREIN ARE TRUE. THE UNDERSIGNED AGREES THAT IF THE INFORMATION SUPPLIED ON THIS APPLICATION CHANGES BETWEEN THE DATE OF THIS APPLICATION AND THE EFFECTIVE DATE OF THE INSURANCE, HE/SHE (UNDERSIGNED) WILL IMMEDIATELY NOTIFY THE INSURANCE COMPANY OF SUCH CHANGES, AND THE COMPANY MAY WITHDRAW OR MODIFY ANY OUTSTANDING QUOTATIONS AND/OR AUTHORIZATION OR AGREEMENT TO BIND INSURANCE.
Applicant Name:*

First NameLast Name
By:*
Date*

MonthDayYear
Date
Signature*

Clear
Title*
Producing Agent*
Name*

First NameLast Name
Agency*
Phone Number*
Please enter a valid phone number.
License #*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Signature*

Clear
Should be Empty:

	In Force	Being Considered	Vendor	Employee	Projected Revenue
Accounting/Tax Preparation
Closing Attorney
Data Processing for Others
Discount/Securities Brokerage
Insurance Agency/Sales
Investment/Financial Planning
Loan Servicing for Others
Notary Public Services
Real Estate Appraisal Services
Property Management
Finance Company (Sub-prime Lending)
Trust Department (Separate App Required)
Safety Deposit Box or Vault Services

	Service	In Force	Being Considered	Vendor	Employee	Projected Revenue
1
2

	Dollar Amount Most Recent Examination	Dollar Amount Previous Examination
Substandard
Doubtful
Loss

	Yes	No
11. Are surveillance cameras positioned on all corridors, offices, entrances, exits, ATM’s teller stations, safe and, safe deposit /or vault areas and drive through lanes?
12. Does the bank have a silent robbery alarm system?
13. Are there formal, written opening and closing procedures?
14. Do bank personnel regularly receive robbery training?
15. Are there surprise counts of tellers’ cash and vault cash?
16. Are tellers’ cash drawers under the exclusive control of one employee?
17. Are tellers trained on how to detect check kiting?
18. Do tellers regularly receive check fraud and forgery training?
19. Does the data processing system prohibit employees from posting transactions to their own accounts?

	Yes	No
a. establish individual teller check cashing authority?
b. address check holds?
c. address cashing checks for non-customers

	Yes	No
26. Are there written, new account procedures?
27. Does the bank utilize any identity verification authentication services or tools?
28. Are ChexSystems and/or credit reports pulled on all new customers?
29. Are extended check holds placed on new accounts?
30. Does the bank allow customers to open new accounts electronically (on-line)?

	Yes	No
a. a credit card?
b. a debit card?
c. transferring funds electronically?

	Yes	No
a. non-financial/maintenance transactions?
b. check kiting?
c. dormant/inactive accounts?

	Yes	No
36. Are dormant accounts identified, segregated and maintained under dual control?
37. Does every employee have their own user ID (no shared access)?
38. Are passwords required for each user ID?
39. Are passwords set to expire at least every 60 days?
40. Is the ID locked out after 3 unsuccessful attempts?
41. Are access violations reported and reviewed by someone in a senior management capacity?

	Yes	No
43. Is the network protected by an intrusion detection system?
44. Is the system protected by a virus scanning system?
45. Is the system protected by automatic vulnerability assessments?
46. Does the home banking/audio response system block access after 3 failed attempts?
47. Does the bank validate on-line requests for large check withdrawals by direct contact with depositors?
48. Is there a formal, written loan policy?
49. Is the loan policy reviewed and approved annually by the board of directors?

	Yes	No
a. define the types of loans granted and state the amount of each type as either a percentage of loans or assets, or as a set dollar amount?
b. state the terms and rates?
c. define acceptable collateral?
d. establish aggregate credit lines per borrower?
e. specify individual lending personnel authority?
f. specify how exceptions to policy are to be handled?
g. specify guidelines for extensions, renewals, and refinancing?

	Name of Owners	Percentage Owned
1
2
3

	Principal Place of Business	Percentage Owned	Nature of Business
1
2
3
4

	Shareholder Name	% Owned
1
2
3

FORTEGRA SPECIALTY INSURANCE COMPANY