Name: Brokers' Risk
Brand: Brokers' Risk

Page 1 of 12

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How did you hear about the Brokers' Risk Trustees' E&O Coverage?

Name of Trust/Self Insured Fund / Pool / JPA (Trust)

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Required

What legal authority was used to establish the Trust?

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Required

Names of Trustees/Board Members

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Does the Trust have employees?

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YesNo

Required

If Yes, Total Number of Employees

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Address of the Trust

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City

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Required

State

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Phone

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Zip

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Fax

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When was the Trust established?

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Type of Self Insured Trust

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Required

please describe

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Name of Program Administrator

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Is the Program Administrator an employee of the Trust?

YesNo Invalid Input

10)

Address of Administrator’s Office

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City

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State

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Zip

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11)

Name of Custodian of Securities

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12)

Name of Accountant

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13)

Name of Auditing Firm

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14)

Fiscal Year

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15)

Name of Investment Counselor

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16)

Does Investment Counselor have authority to make investment decisions?

YesNo Invalid Input

17)

Are there State Regulations governing the investment of funds?

YesNo Invalid Input

If yes, do the Trust’s investment guidelines comply with the State Regulation?

YesNo Invalid Input

18)

Name of Actuarial Consultant

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19)

How often is the actuarial study completed?

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20)

Name of General Counsel

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21)

State amount of Fidelity Bond in force for the Program Administrator

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22)

State amount of Fidelity Bond in force for the Claim Administrator

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23)

Does state regulator require security?

YesNo Invalid Input

If Yes, how much?

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How is security provided?

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24)

Name of the Claims Administrator?

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25)

Does the claims administrator handle safety engineering/loss control?

YesNo Invalid Input

If No, who does?

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26)

Does the Program Administrator handle Marketing and Underwriting?

YesNo Invalid Input

If No, who does?

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27)

Are there any loans outstanding to the Trust?

YesNo Invalid Input

If Yes, please state amount

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What is the amount of delinquent accounts receivable?

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Receivable in Excess of 60 days

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28)

Please attach a full copy of all:

Aggregate Excess

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Re-insurance

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Stop Loss

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Specific Excess

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Insurance Contracts

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29)

Have claims ever been made against any of the present or past Trustees, Program Administrator or the Trust?

YesNo Invalid Input

If Yes, give full particulars

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30)

Has application for insurance by the Trust or Trustees ever been declined? Non-renewed?

YesNo Invalid Input

If Yes, give full particulars

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31)

Has E&O and/or D&O insurance covering the Trust, Trustees, or Program Administrator ever been cancelled?

YesNo Invalid Input

If Yes, give full particulars

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32)

Is the Trust, Trustees, or Program Administrator aware of any circumstances that might give rise to a claim being made against the Trust, Trustees, or Program Administrator?

YesNo Invalid Input

If Yes, give full particulars

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33)

Do you have a Participation Contract or Indemnification Agreement between the member entity and the Trust?

YesNo Invalid Input

34)

Please state Total Number of member entities and Employees

Member Entities

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Employees

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35)

Estimated Annual Contributions for current plan year

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36)

Estimated Annual Contributions for next plan year

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37)

Amount of Indemnity requested

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other $

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38)

Deductible Requested

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other $

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Please attach copies of following documents:

Service contract between the Trust and the Program Administrator

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Service contract(s) between the Trust and the Marketing

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Copy of the Trust’s Underwriting Guidelines

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Full copy(s) of all excess policies and reinsurance treaties for all lines of coverage offered by the Trust

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Trust Document and Bylaws

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Service contract(s) between the Trust and the Claims Administrator

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Last two Audited Financial Statements

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If Fund performs in-house claims administration, please attach resumes of key claims personnel

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Sample copy of Coverage Document including Declarations

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Service contract(s) between the Trust and the Loss Control / Safety Engineering Administration

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Latest actuarial study

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Participation Contract or Indemnification Agreement between the member entity and

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Warranty

The Undersigned declare that to the best of their knowledge the statements set forth herein and any documents and information submitted in connection herewith are true, accurate and complete and that every effort has been made to obtain sufficient information from each and every person proposed for this coverage to facilitate the proper and accurate completion of this Application Form. The undersigned further declare that they have not suppressed, omitted, or misstated any material facts. The undersigned agree that if the information supplied on or in connection with this Application Form changes between the date of this Application and the effective date of the coverage, the undersigned will immediately notify Brokers’ Risk Placement Service, Inc. and Brokers’ Risk Placement Service, Inc., in its sole discretion, may withdraw or modify any outstanding quotations or authorization or agreement to bind coverage. The signing of this Application Form does not bind the applicant to purchase the coverage. However, it is agreed that this Application Form and any documents or information submitted herewith shall be the basis of the contract should a Coverage Agreement be issued and are to be considered as incorporated in and constituting part of the Coverage Agreement.

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Yes, I have read the Warranty.

Required

This application must be signed and dated by an Officer of the Trust, and not earlier than 60 days before the proposed effective date.

Digital Signature

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Required

By typing your name in this box and clicking submit you are accepting the terms of this Application Form.

Title

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Applicant's Email

Required

All data on this Application Form is considered highly confidential and is for Underwriters’ use. Signing this Application Form does not bind the Underwriters to provide any Insurance, but it is agreed that this Application Form shall be made a part of the policy and shall be the basis of the contract should a policy be issued.

Security Code ◄

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