PLAZA INSURANCE COMPANY a member of the State Auto Group Application for Fiduciary Liability Coverage GENERAL INFORMATION Parent Company: Address: Website: State of Incorporation: Years of Operation: Type of Business Entity: Corporation LLC Sole Proprietor Partnership Nature of Operations: SIC Code: Limits Requested: Retention Requested: Policy Period requested: From: To: Has any insurance carrier refused, cancelled, or non-renewed any coverage for which this applicant is applying for? Yes No EMPLOYEE BENEFIT PLAN(S) INFORMATION List all plans for which coverage is desired: Total Number Active Number Total Type Full Name of Plan of Plan of Plan Plan of Participants Participants Assets Plan* *Types of Plans: Employee Stock Ownership Plan = ESOP Defined Benefit Plan = DB Defined Contribution Plan = DC Excess Benefit Plan = EB Welfare Benefit Plan = WB MK-938 MK-922 Plaza (07/11) Insurance (10/11)
Do any of the plans employ the services of: Service Provider Yes No If Yes, Name Years Engaged Investment Manager Professional Actuarial firm Outside Legal Counsel CPA Is any Plan listed in Question #1 a multiemployer or multiple employer plan?... If Yes, please provide additional details on a separate attachment, including past and anticipated future Plan merger activity (if any). What percentage of Plan assets are managed by an investment manager as defined in ERISA? How often is the Plan s investment manager s performance reviewed? If the services of an investment manager are employed, does the investment manager have discretionary control over the investing of the total plan assets?... Are any investment decisions handled in-house?... If Yes, please provide details. Has an actuary certified that the plans are adequately funded?... In the last two (2) years, has the Applicant or any Subsidiary spun-off, merged or terminated any Plan and is any such event contemplated within the next two (2) years? If yes, please provide additional details on a separate attachment.... In the last two (2) years, has the Applicant or any Subsidiary adopted any amendment to any Plan listed above that resulted in or is expected to result in any reduction of benefits, cessation of benefits, or increase in costs to the Plan participants?... Is any such amendment anticipated in the next twelve (12) months?... Does the Applicant or any Subsidiary have any outstanding delinquent contributions to any Plan?... Does any Plan listed above hold or invest in securities of the sponsor organization or of any Subsidiary or Affiliate?... Have any fees, fines or penalties been assessed against any Plan of the Applicant or any Subsidiary under any voluntary compliance program or similar voluntary settlement program?... Are all defined benefit plans funded in accordance with ERISA (or any other applicable similar law)?... Are there any overdue employer contributions for any Plan?... Has any Plan requested or considered filing a request for a waiver of contributions?... YES NO
Is plan administration reviewed periodically to assure that there are no violations of any plan trust agreements, prohibited transactions or party-in-interest rules?... Have you amended your plan(s) (if necessary) to comply with the Employee Retirement Income Security Act of 1974 (ERISA), including, but not limited to, standards of eligibility, participation and vesting?... YES NO Do you issue a report to all participants about the plan(s) performance annually?... PAST ACTIVITIES AND CURRENT COVERAGE In the past three (3) years, have there been any plan mergers or plan terminations?... If Yes, please attach details including the name of the insurer if benefits were secured by the purchase of annuities. Has the Parent Company, any Subsidiary, any director, officer, Fiduciary or other proposed Insured Person been involved in any of the following (If Yes to any of these attach details): accused, found guilty or held liable for a breach of ERISA or similar law?... civil or criminal action or administrative proceeding charging violation of a federal or state security law or regulation?... any other criminal actions?... representative actions, class actions or derivative suits?... Has the Parent Company, any Subsidiary or any Insured Person given written notice under the provisions of any prior or current fiduciary liability coverage or similar insurance or endorsement of specific facts or circumstances which might give rise to a Claim being made against any Insured? If Yes, attach details.... Have any Loss Payments been made on behalf of any Insured under any fiduciary liability policy or similar insurance or endorsement? If Yes, attach details.... CURRENT COVERAGE Name of Insurance Company Limit of Liability Self Insured Retention Policy Effective Date Premium Pending and Prior Litigation
PRIOR KNOWLEDGE / REPRESENTATION IT IS IMPORTANT THAT YOU COMPLETE ONE OF THE BLANKS IN THIS PARAGRAPH. No person proposed for coverage is aware of any facts, circumstances, investigations or actions which he or she has reason to suppose might give rise to a future Claim that would fall within the scope of proposed coverage, except None; Or It is agreed that if such facts, circumstances, investigations or actions exist, whether or not disclosed, any Claim arising from them is excluded from this proposed coverage. Attach copies of the following for the Applicant and, to the extent available, each of its Subsidiaries: A copy of the most recent IRS Form 5500, including Schedules A and B or IRS Form 5500-C (if applicable). A copy of the most recent audit report of any plan(s) proposed for coverage. A copy of the most recent actuarial report (if applicable). A copy of the most recent independent audit report of the Parent Company. Details regarding any Claims that have occurred within the last three (3) years IMPORTANT INFORMATION The submitting of this Application does not obligate the Insurer to issue a coverage section. You will be advised if your Application for insurance is accepted. FALSE INFORMATION Any person who, knowingly and with the intent to defraud any insurance company or other person, files an Application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime. MATERIAL CHANGE Signing of this Application does not bind the Parent Company or the Insurer. If there is any material change in the answers to the questions prior to the Policy inception date the Parent Company will notify the Insurer in writing and any outstanding quotation or indication may be modified or withdrawn. DECLARATION AND SIGNATURE The undersigned declares that to the best of his or her knowledge and belief that the statements set forth herein are true. Although the signing of this Application does not bind the undersigned on behalf of the Parent Company or any other proposed Insured to effect insurance, the undersigned agrees that this Application and its attachments shall be the basis of the contract should a Policy be issued and shall be deemed attached to and shall form part of the Policy. The Insurer is hereby authorized to make any investigation and inquiry in connection with this Application that it deems necessary. Application must be signed by the Plan Administrator. Date Signature Title
NOTICE TO APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COM- PANY 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 CONCERN- ING ANY FACT MATERIAL THERETO, COMMITS A FRAUDU- LENT ACT, WHICH IS A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. NOTICE TO ARKANSAS, NEW MEXICO 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 INFORMA- TION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINE- MENT IN PRISON. NOTICE TO COLORADO APPLICANTS: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEAD- ING FACTS OR INFORMATION TO AN INSURANCE COMPA- NY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE INSURANCE 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 A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DE- PARTMENT OF REGULATORY AUTHORITIES NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARN- ING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PEN- ALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN AD- DITION, 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 IN THE THIRD DEGREE. NOTICE TO KENTUCKY APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSUR- ANCE COMPANY OR OTHER PERSON FILES AN APPLICA- TION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSUR- ANCE ACT, WHICH IS A CRIME. NOTICE TO LOUISIANA 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 MAINE APPLICANTS: IT IS A CRIME TO KNOW- INGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE INSURANCE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES OR A 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 BEN- EFIT OR WHO KNOWINGLY AND WILLFULLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSUR- ANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON. NOTICE 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. NOTICE TO OHIO APPLICANTS: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILI- TATING 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 OKLAHOMA APPLICANTS: WARNING: ANY PER- SON WHO KNOWINGLY, AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAIN- ING ANY FALSE, INCOMPLETE OR MISLEADING INFORMA- TION IS GUILTY OF A FELONY (365:15-1-10, 36 3613.1). NOTICE TO PENNSYLVANIA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFOR- MATION 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 TENNESSEE, VIRGINIA AND WASHINGTON AP- PLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN IN- SURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE INSURANCE COMPANY. PENALTIES INCLUDE IMPRIS- ONMENT, FINES AND DENIAL OF INSURANCE BENEFITS. NOTICE TO VERMONT APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY CONTAINING ANY MATERIALLY FALSE INFORMATION OR, CONCEALS, FOR THE PURPOSE OF MISLEADING, INFOR- MATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT ACT, WHICH MAY BE A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. NOTICE TO NEW YORK APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMA- TION CONCERNING ANY FACT MATERIAL THERETO, COM- MITS 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.