• 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.

  • 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:

  • Format: (000) 000-0000.

  • 2. Please provide the following current insurance information:

  • Have the above coverage(s) been declined, canceled or non-renewed in the past three (3) years?*

  • B. GENERAL INFORMATION

  • C. MANAGEMENT AND OWNERSHIP

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  • Provide the following information for all subsidiaries, including subsidiaries of subsidiaries, of the applicant:

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  • It is agreed that coverage will not be provided for any subsidiary unless listed above or listed in an attachment to this application. Please note that listing in this application does not automatically extend coverage to the subsidiary, if the policy is issued. Such coverage shall only be afforded if coverage is extended either by listing in the Declarations, by definition, specific provision, or by endorsement.

  • 2. Have there been any changes in Chairman of the Board, President, Executive Vice President, Chief Financial Officer, Chief Operation Officer, Chief Lending Officer or other senior management in the past 5 years?*

  • 3. Please provide the following:

  • a. Common Stock*
  • b. Publicly Traded*

  • e. Provide the names of any shareholders owning directly or beneficially 10% or more ofthe shares of the applicant and indicate the % owned by each.

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  • f. Has there been a change in controlling ownership (10% or more) in the past 5 years?*
  • 4. Are there any negotiations pending for the sale by anyone of stock of this applicant in excess of: 10%?*
  • 5. Has this applicant been involved in any actual or proposed merger, acquisition or divestment in the past 5 years?*
  • 6. Has any regulatory agency denied or indicated they would deny any contemplated merger, acquisition or divestment in the past 5 years?*
  • 7. Does the applicant’s lending to any one insider, as defined by FDIC Regulation O, exceed 10% of the applicant’s equity capital?*
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  • 8. Are any insider loans past due or classified?*
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  • 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?*
  • 2. Has the applicant sustained any loss in excess of the deductible under its Financial Institution Bond within the past 5 years?*
  • 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?*
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  • It is agreed that any claim related to or arising from these disclosures is/are herein excluded from coverage.

  • E. PROFESSIONAL SERVICES:

  • 1. If the applicant offers or plans to offer any of the following services, indicate such and if they are, or will be, performed by employees of the applicant or by an outside vendor along with the annual revenue derived from the service.

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  • Are any other services provided or being considered?*
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  • 2. Are specific errors and omissions insurance policies maintained for any and/or each of the listed services offered?*
  • 3. If discount and/or security brokerage services are offered, are there clear disclaimers that such investments are not insured and that their value may decrease?*

  • F. REGULATORY CONSIDERATIONS:

  • 1. Have regulators assigned your institution a CAMEL rating other than a “1” or a “2” as a result of the most recently completed regulatory examination (Safety and Soundness)?*
  • 3. Is the applicant operating under a Cease-and-Desist Order, Memorandum of Understanding or similar agreement with any regulatory agency?*
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  • 4. Were total adversely classified assets from the most recent regulatory exam in excess of 50% of  capital?*

  • If yes, please provide a summary of such classifications as well as an attachment of an action plan for reducing the amount of adversely classified assets.

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  • 5. Were there any violations of law or regulation cited as a result of the most recent regulatory exam?*
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  • 6. Have all criticisms from the most recent regulatory exam been reviewed by the Board of Directors and have appropriate corrective actions been taken?*
  • 7. During the past 3 years, has the applicant been alerted to any concentration of credit that warranted a reduction or correction?*
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  • 8. During the past 3 years, has the applicant been alerted to any extension of credit that exceeds the Legal Lending Limit?*
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  • G. GENERAL OPERATIONAL INQUIRIES:

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  • 2. Does the applicant participate on loans originated by other financial institutions?*
  • 3. Does the applicant require all officers and employees to be away from work at least 9 consecutive days (one week vacation and adjoining weekends)?*
  • 4. Does the applicant have a continuous internal audit by an internal auditor who reports directly to the Board of Directors?*
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  • 9. Is the bank currently providing or considering transporting cash and/or securities for customers?*
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  • 20. Is there a written check cashing policy?*
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  • 21. Are there written agreements/disclosures with all customers requesting wire transfers?*
  • 22. Is identification required for all funds transfer requests including phone, fax, mail and other electronic means or devices?*
  • 23. Are callbacks required for all phone, fax, mail and other electronic secured devices?*
  • 24. Does a person other than the person receiving the funds transfer request perform the callback?*
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  • 31. Are access levels assigned by job function?*
  • 32. Are supervisory overrides required for critical transactions?*
  • 33. Has the applicant within the last 24 months changed, upgraded, or enhanced its computer systems, electronic data storage or retrieval systems, its data processing systems, or any other electronic operating programs or systems?*
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  • 42. Is there any dial-up or remote access to the system?*
  • If yes, is such access protected with passwords or dial-backs?*
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  • 51. Is there a periodic review/audit of loan files to determine adherence to written policies and procedures?*
  • 52. Is there an audit procedure in place to review new loan advances to test their legitimacy?*
  • 53. Are all employee loans approved by senior management?*
  • 54. Are all loans to management, officials and their family members approved by someone who is not subordinate to the applicant?*
  • 55. Are all employee deposit accounts reviewed for unusual activity?*
  • 56. Are all new and renewal loan applications and documents required to be signed in the presence of a bank officer?*
  • 57. Are all data and collateral obtained in conjunction with loans verified as genuine before loan proceeds are disbursed?*
  • 58. Is all negotiable collateral maintained under dual control?*
  • 59. Are any signed, blank notes maintained on premises kept under dual control?*
  • 60. Are loans made outside of the bank’s defined trade territory?*
  • 61. Is the Board of Directors apprised of the delinquency status of the loan portfolio on a regular basis?*

  • H. EMPLOYMENT RELATED INQUIRIES:

  • 1. In the past 12 months, have there been any main offices or branch office closings, layoffs, terminations or reorganizations?*
  • 2. Are there any main office or branch office closings, layoffs, terminations or reorganizations contemplated in the next 12 months?*
  • 3. Does the applicant have written human resources policies, including policies against sexual harassment, and have such policies been reviewed by an attorney?*
  • If yes, does the applicant have the human resource policies, including all written manuals and other materials, reviewed periodically?*
  • 4. Does the applicant use written employment applications that include employment at will statements?*
  • 5. Do any Directors, Officers or employees of the applicant travel outside the US on business for the applicant?*

  • I. COVERAGE REQUEST(S):

  • 1. Please provide desired coverage options and advise if different from expiring terms and conditions:

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

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  • 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?*
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  • 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:*
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  • 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.

  • Date*
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  • Format: (000) 000-0000.
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