Securities Dealer Blanket Bond
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1 Securities Dealer Blanket Bond FINRA-sponsored Insurance Program c/o Seabury & Smith, Inc Meredith Drive P.O. Box Urbandale, IA Toll-Free Most broker-dealer firms rely on the Securities Dealer Blanket Bond to protect their assets. Here s why: Seabury & Smith originated the Securities Dealer Blanket Bond, one of the most comprehensive Fidelity Bonds in the marketplace. Online Enrollment In just a few minutes you can apply for, purchase and have your bond issued online at (for limits up to $500,000). Everything can be handled conveniently online from initial quoting to immediate coverage and 24/7 access to your account for renewals. Discounts available for new clients and for two-year prepaid bonds (for limits up to $500,000). Limit applies to each and every loss (unlike the Standard Form 14 in which coverage ceases to exist after the aggregate losses meet the bond limit). Includes coverage for Registered Representatives. Defense cost for covered losses is in addition to the limit of liability. This Fidelity Bond can provide coverage for your in-house pension and profit-sharing plan at no additional cost to your firm. Seabury & Smith, Inc., annually reviews the product to ensure competitive pricing and quality coverage. We are proud to consistently present firms with stable or reduced rates. We are committed to customer service excellence serving firms of all sizes. Financial Services Industry Experts: Our underwriting team has more than 100 years combined experience in administering insurance products for broker-dealers, and we understand the unique nature of the Securities Industry. Seabury & Smith, Inc., FINRA s insurance program administrator, has partnered with FINRA Member Benefits for more than two decades to provide quality insurance solutions to broker-dealers. FINRA is a trademark of the Financial Industry Regulatory Authority, Inc. Seabury & Smith, Inc., FINRA s insurance program administrator, is a third-party provider of insurance products. It is in no way owned or managed by FINRA.
2 Answers to the most frequently asked questions Q. What is a Fidelity Bond, and why does my firm need one? A. A Fidelity Bond insures your firm against intentional fraudulent and dishonest acts committed by your employees and registered representatives under certain specified circumstances. In cases of theft of customer funds, a Fidelity Bond generally will indemnify your firm for covered losses sustained in the handling of customers accounts. Besides being an SEC requirement, having a Fidelity Bond just makes good business sense. Q. How do I determine what minimum limit of liability I need to carry? A. According to section 3020 of the FINRA Manual, if your required net capital under SEC Rule 15c3-1 is up to $600,000, then you are required to carry a Fidelity Bond in the amount of 120 percent of your required net capital or $25,000, whichever is greater. If your required net capital is more than $600,000, please refer to the chart in Question 5 of the attached application. Q. Does this policy satisfy the ERISA Fidelity Bond requirements for my in-house pension and profitsharing plans? A. Our Fidelity Bond allows you to add these plans at no additional cost, subject to the limit of your firm s Fidelity Bond. If your firm s limit falls short in satisfying your ERISA requirements, you will still need to carry a separate ERISA Bond for those plans unless you choose to increase your firm s Fidelity Bond to the limit of your ERISA requirement. If you require a separate ERISA Bond, Seabury & Smith also offers this product. Q. What is the FINRA-sponsored Insurance Program? A. The FINRA-sponsored Insurance Program consists of a broad range of products assembled exclusively for broker-dealer firms. Seabury & Smith, Inc., is FINRA s insurance program administrator. We are a thirdparty provider of insurance products. We are not owned or managed by FINRA. We assist firms in obtaining insurance coverage for virtually all business risks faced by a broker-dealer. Q. What other products are available to broker-dealer firms? A. Seabury & Smith offers several insurance products including Errors & Omissions Liability, Directors & Officers Liability, Signature Guarantee Medallion Bonds, ERISA Bonds, Employment Practices Liability, Business Owners Policies and much more. For more information on these or other products, please contact us at or visit our Web site at Features of the Securities Dealer Blanket Bond Protection for your firm against intentional and dishonest acts committed by your employees and registered representatives. Limits available from $25,000 to $5 million. Limit applies to Each and Every Loss as opposed to the Standard Form 14 coverage, which ceases to exist for the remainder of the policy term after the aggregate losses meet the bond limit. Defense cost for covered losses is available in addition to the limit of liability. Option to purchase a one-year discovery period upon bond cancellation affording an additional 12 months to discover losses that were sustained during the bond period. Additional Automatic Coverages:* Computer Systems Fraud Covers loss from a fraudulent entry, or change of electronic data or computer program. Applicable to any computer system operated by the insured. Computer Virus Covers loss due to a computer virus that causes the insured to transfer, pay or deliver funds or property, establish credit or give any value as the direct result of malicious damage or destruction to the insured s computer system. Telefacsimile Transfer Fraud Covers loss resulting directly from the insured having in good faith, transferred funds, certificated securities or uncertificated securities through a computer system covered under the terms of the Computer System Fraud insurance agreement due to their reliance on a fraudulent instruction received through a Telefacsimile Device. Voice-Initiated Transfer Fraud Covers loss resulting directly from the insured having in good faith, transferred funds from a customer s account through a computer system covered under the terms of the Computer System Fraud insurance agreement due to their reliance on a fraudulent instruction transmitted by telephone. Audit Expense (Aggregate Limit $25,000; Subject to $5,000 Deductible) Covers expenses incurred by the insured for the costs of audits or examinations required by any governmental regulatory authority for reason of discovery of a loss sustained by a dishonest or fraudulent act of an employee. Unauthorized Signatures (Aggregate Limit $25,000; Subject to $5,000 Deductible) Covers loss resulting from the insured having accepted, paid or cashed any check or withdrawal order made or drawn on a customer s account which bears the signature of one other than a person whose name and signature is on file with the insured as a signatory on such account. Uncollectible Items of Deposit ($25,000 Occurrence Limit; $100,000 Aggregate Limit; $5,000 Deductible) Loss resulting from payments of dividends or funds shares, or withdrawals from a customer s account as a direct result of items of deposit that are not paid for any reason. Credit Card Forgery Covers loss which the Insured shall sustain through forgery or alteration of, on or in, any written instrument required in conjunction with any business credit card issued to the Insured or to any partner, officer or employee of the Insured. *Additional conditions of coverage apply and are detailed in applicable riders.
3 Securities Dealer Blanket Bond Application Eligibility Requirements Bond limits from $25,000 to $5 million (Limits in excess of $1 million must complete the Form 14 Broker-Dealer Fidelity Bond Application) No claims made under your Fidelity Bond in the past five years Maximum of 2,500 employees including registered representatives Maximum of 200 branches (excluding main office) No additional coverage requested in addition to the automatic riders Home office is domiciled within the United States Applicant Information Broker-Dealer Firm Name Contact Person BD # Street Address City State ZIP Phone Fax Web site Additional Joint Insureds (e.g., operating subsidiaries or your own pension plans. NOTE: Clearing brokers cannot be considered as additional joint insureds.) Underwriting Information 1. Desired effective date 2. Number of registered representatives Number of employees (not counted above) 3. Total number of branches (excluding main office) A branch office is defined as an office which is owned or controlled by a member firm, and which is engaged in the investment banking or securities business. 4. Highest Minimum Net Capital Requirement in the past 12 months 5. Minimum required bond amount (Net Capital Requirement x 120%) Minimum required bond amount is determined by your highest net capital requirement in the past 12 months up to and including $600,000 multiplied by 120 percent. If your highest net capital requirement is more than $600,000, use the following chart: Net Capital Requirement Minimum Required Bond Amount $600,001 1,000, ,000 $1,000,001 2,000,000 1,000,000 $2,000,001 3,000,000 1,500,000 $3,000,001 4,000,000 2,000,000 $4,000,001 6,000,000 3,000,000 $6,000,001 12,000,000 4,000,000 $12,000,001 and above 5,000,000
4 6. Desired bond limit Deductible: Bond Limit $25,000 to $250,000 = $5,000 deductible Bond Limit $275,000 to $1 million = $10,000 deductible 7. Exchanges of which you are a member, (please check all that apply): Boston Stock Exchange Chicago Stock Exchange Pacific Stock Exchange Stock Clearing Corporation of Philadelphia Chicago Board of Trade Chicago Board of Exchange American Stock Exchange 8. Are you registered to do business in the state of Arkansas? Yes No 9. If you are fully disclosed, please list your clearing broker 10. During the past five years, were any of your firm s current or past registered representatives fined, penalized or suspended while with your firm? Yes No If Yes, please provide a complete Form U-4 including DRP for each incident: # of incidents Date of such incidents Amount ($) of each incident Cause of each incident 11. Year broker-dealer established If your firm does not meet the Eligibility Requirements for the Securities Dealer Blanket Bond, we would be pleased to prepare an alternate premium quotation upon receipt of our Form 14 Broker-Dealer Fidelity Bond application in addition to the following: 1. Financial statement and Focus II Reports for the past two quarters. 2. Copy of most current CPA audit (if available). 3. CPA Management letter and your response (if available). 4. Descriptions of claims, if any, including amounts and remedial actions taken. Additional Information 12. Please indicate how you acquired this application: Mailing Conference Web site Requested Provided by a consultant Other 13. Prior insurance carrier Expiration date Annual premium 14. Do you currently have any of the following products? Errors & Omissions Liability Insurance Yes No Expiration Date Directors & Officers Liability Insurance Yes No Expiration Date Fiduciary Liability Insurance Yes No Expiration Date Employment Practices Liability Insurance Yes No Expiration Date ERISA Bond Yes No Expiration Date Signature Guarantee Medallion Bond Yes No Expiration Date Business Owners, Workers Compensation, Business Auto, Excess Liability Yes No Expiration Date If you do not currently have these coverages with us, may we contact you to discuss our product line and obtain additional information to provide you with a quotation for those coverages you have an interest in? Yes No If Yes, please provide contact name and preferred method of contact Phone Mail Any
5 Securities Dealer Blanket Bond New Business Premium Calculation Use this form to calculate your firm s premium. If you have any questions, please feel free to contact us at or us at insuranceinfo@seaburyandsmith.com. FINRA-sponsored Insurance Program c/o Seabury & Smith, Inc., Meredith Drive P.O. Box Urbandale, IA In order to compute premium, follow steps as indicated: Bond Limit Requested $ Number of Employees (salaried plus Registered Representatives) Requested Effective Date 1) BASE PREMIUM Refer to charts on following pages and enter the appropriate figure on line (A) (A) 2) BRANCH CHARGE Number of Branches Branches Base Premium (A) 0 x 1.00 $ 1 5 x 1.20 $ 6 25 x 1.45 $ x 1.55 $ x 1.85 $ x 1.90 $ Enter appropriate figure on line (B) (B) * 3) SELECT YOUR DISCOUNT Please rate for either the one or two-year policy option. 1 Year Policy (5% discount on first-year premium) (B) x 0.95 $ or 2 Year Policy** (10% discount) (B) x 0.90 x2 $ **For limits up to $500,000 Enter appropriate figure in line (C) (Total Premium) (C) * Total Premium *Always round Premium to the nearest whole dollar. FINRA is a trademark of the Financial Industry Regulatory Authority, Inc. Seabury & Smith, Inc., FINRA s insurance program administrator, is a third-party provider of insurance products. It is in no way owned or managed by FINRA.
6 BASE CHART I 50 EMPLOYEES OR FEWER BOND AMOUNT 1 5 NUMBER OF EMPLOYEES If you have 50 employees or fewer, locate the appropriate boxed figure on the horizontal axis and enter the figure that corresponds to your Desired Bond Amount on line (A). 25,000 30,000 35,000 40,000 45,000 50,000 60,000 75, , , , , , , , , , , , , , , , , , , , ,004 1,023 1,098 1,189 1,278 1,371 1,448 1,491 1,536 1,552 1,571 1,594 1,617 1,635 1, ,075 1,185 1,207 1,293 1,397 1,500 1,607 1,696 1,753 1,813 1,842 1,878 1,916 1,953 1,962 1, ,016 1,108 1,131 1,243 1,366 1,391 1,488 1,605 1,721 1,843 1,944 2,015 2,090 2,132 2,185 2,237 2,289 2,314 2, ,010 1,159 1,261 1,287 1,411 1,547 1,575 1,682 1,813 1,942 2,079 2,192 2,278 2,367 2,423 2,492 2,559 2,625 2,666 2, ,034 1,138 1,302 1,413 1,442 1,579 1,728 1,758 1,877 2,021 2,164 2,315 2,440 2,540 2,644 2,713 2,800 2,880 2,961 3,017 3, ,033 1,074 1,154 1,267 1,446 1,566 1,597 1,747 1,909 1,942 2,071 2,229 2,385 2,550 2,688 2,802 2,921 3,003 3,107 3,202 3,297 3,369 3, ,003 1,051 1,098 1,144 1,188 1,274 1,396 1,589 1,719 1,752 1,914 2,090 2,126 2,266 2,436 2,607 2,786 2,936 3,064 3,198 3,294 3,414 3,523 3,633 3,721 3,811 1,050 1,104 1,156 1,206 1,254 1,302 1,394 1,525 1,732 1,872 1,908 2,082 2,272 2,310 2,460 2,644 2,828 3,022 3,184 3,326 3,475 3,584 3,721 3,845 3,969 4,072 4,179 1,148 1,205 1,260 1,313 1,365 1,416 1,513 1,653 1,876 2,024 2,063 2,250 2,453 2,494 2,655 2,852 3,050 3,258 3,432 3,588 3,752 3,874 4,028 4,166 4,305 4,424 4,546 1,246 1,307 1,365 1,421 1,476 1,530 1,633 1,782 2,019 2,177 2,218 2,418 2,634 2,677 2,850 3,060 3,271 3,494 3,680 3,850 4,029 4,165 4,335 4,488 4,641 4,776 4,914 For limits in excess of $500,000, please call to speak with a Seabury & Smith Underwriter who can assist you with your request. BASE CHART II MORE THAN 50 EMPLOYEES BOND AMOUNT NUMBER OF EMPLOYEES If you have more than 50 employees, locate the appropriate boxed figure on the horizontal axis and enter the figure that corresponds to your Desired Bond Amount on line (A). 25,000 30,000 35,000 40,000 45,000 50,000 60,000 75, , , , , , , , , , , , , , , , , , , ,000 1,736 1,813 1,887 1,959 2,030 2,099 2,233 2,426 2,735 2,941 2,995 3,257 3,539 3,597 3,823 4,100 4,378 4,673 4,920 5,161 5,414 5,616 5,870 6,096 6,321 6,534 6,753 2,115 2,203 2,289 2,373 2,454 2,535 2,690 2,916 3,279 3,531 3,595 3,905 4,239 4,307 4,575 4,903 5,234 5,585 5,879 6,174 6,485 6,738 7,057 7,338 7,620 7,893 8,174 2,444 2,543 2,638 2,732 2,823 2,913 3,088 3,342 3,751 4,074 4,124 4,460 4,828 4,902 5,195 5,553 5,911 6,291 6,607 6,924 7,259 7,532 7,876 8,176 8,476 8,768 9,066 2,734 2,845 2,953 3,057 3,159 3,260 3,453 3,733 4,179 4,531 4,590 4,950 5,347 5,426 5,742 6,125 6,508 6,914 7,248 7,586 7,941 8,231 8,598 8,914 9,231 9,538 9,852 3,024 3,148 3,267 3,383 3,495 3,606 3,818 4,123 4,608 4,988 5,056 5,440 5,865 5,951 6,289 6,697 7,105 7,537 7,890 8,248 8,623 8,930 9,319 9,653 9,986 10,308 10,638 3,314 3,450 3,581 3,708 3,831 3,952 4,183 4,514 5,037 5,445 5,523 5,929 6,384 6,475 6,835 7,270 7,702 8,160 8,532 8,909 9,306 9,629 10,041 10,391 10,741 11,079 11,424 3,603 3,752 3,895 4,033 4,167 4,298 4,548 4,905 5,465 5,901 5,988 6,417 6,901 6,998 7,380 7,840 8,297 8,780 9,172 9,569 9,985 10,326 10,761 11,127 11,493 11,847 12,207 3,893 4,055 4,209 4,359 4,503 4,644 4,913 5,295 5,894 6,358 6,454 6,906 7,419 7,523 7,927 8,412 8,894 9,403 9,813 10,230 10,668 11,025 11,482 11,865 12,247 12,617 12,993 4,183 4,357 4,524 4,684 4,839 4,990 5,278 5,686 6,322 6,815 6,920 7,396 7,938 8,047 8,474 8,985 9,491 10,026 10,455 10,892 11,350 11,724 12,204 12,604 13,002 13,388 13,779 4,473 4,660 4,838 5,009 5,175 5,336 5,643 6,077 6,751 7,272 7,387 7,885 8,457 8,572 9,021 9,557 10,088 10,649 11,097 11,553 12,032 12,424 12,926 13,342 13,757 14,158 14,565 5,053 5,264 5,466 5,660 5,847 6,029 6,373 6,858 7,608 8,186 8,319 8,865 9,494 9,621 10,114 10,702 11,281 11,894 12,381 12,877 13,397 13,822 14,370 14,819 15,267 15,699 16,137 5,170 5,400 5,619 5,829 6,031 6,228 6,599 7,121 7,924 8,542 8,507 9,062 9,703 9,832 10,335 10,933 11,522 12,145 12,640 13,144 13,672 14,104 14,661 15,116 15,571 16,010 16,455 For limits in excess of $500,000, or employee counts over 400, please call to speak with a Seabury & Smith Underwriter who can assist you with your request.
7 NOTICE TO 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 act, which is a crime and subjects such person to criminal and civil penalties. NOTICE TO ARKANSAS, LOUISIANA AND 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 FINES AND CONFINEMENT IN PRISON. NOTICE 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 A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AUTHORITIES. NOTICE 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. 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 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. NOTICE TO MAINE 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 MAY INCLUDE IMPRISONMENT, FINES OR A DENIAL OF INSURANCE BENEFITS. NOTICE TO MINNESOTA APPLICANTS: A PERSON WHO SUBMITS AN APPLICATION OR FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD AGAINST AN INSURER IS GUILTY OF A CRIME. 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 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, 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. NOTICE 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. NOTICE 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 (365: , ). NOTICE 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. NOTICE TO TENNESSEE AND VIRGINIA 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 INSURANCE BENEFITS.
8 Transparency & Disclosure Information The Premium rates provided included compensation of 23% of premium from National Union Fire Insurance Company of Pittsburgh, PA received by Seabury & Smith for providing services that may include underwriting applications, issuing policies, ongoing servicing, billing and communications. The base rate filed by the carrier with the applicable state agencies is the same rate provided to you and includes S & S commission. Your payment is your acceptance of Seabury & Smith, Inc. s commission. In this transaction, Seabury & Smith, Inc. is acting as the exclusive insurance agent and program manager for National Union Fire Insurance Company of Pittsburgh, PA., ( Insurer ) for this type of coverage, and not as your insurance broker. As the agent for Insurer Seabury & Smith, Inc. will perform all of the functions necessary to underwriter, quote and, upon acceptance issue this insurance coverage for your firm. Seabury & Smith, Inc. earns and retains interest income on premium held by Seabury & Smith, Inc. on behalf of insurer during the period between receipt of such payments from clients and the time such payments are remitted to the applicable insurer, where permitted by law. Applicant Warranty I understand and acknowledge that I satisfy the Eligibility Requirements as described on this application. I represent that the information furnished in this application is complete, true and accurate. Any intentional misrepresentation, omission, concealment or incorrect statement of a material fact, on this application or otherwise, shall be grounds for rescission of any bond issued in reliance upon such information. I also understand and acknowledge the Seabury & Smith, Inc. Transparency & Disclosure Information listed on this application and my signature is acceptance of these terms. Signature Title Name (please print) Date of Application Call Web Fax Mail Seabury & Smith, Inc. P.O. Box Attn: PF1 FIN Urbandale, IA insuranceinfo@ seaburyandsmith.com A11386 (7/09) Seabury & Smith, Inc d/b/a in CA Seabury & Smith Insurance Program Management; CA#
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