Source: CITA-Cite Benefit Administrators and Consultants E & O Application SECTION I: APPLICANT INFORMATION Full Name of Applicant (include all entities or locations to be insured): Address: Telephone: Email Address: Fax: Website Address: Is the Applicant controlled, owned or associated with any other firm, corporation or company? If provide details. Are any services listed below in Section II provided to such an affiliated enterprise? If provide details If applicant is a Limited Liability Company or Limited Liability Partnership, licensed in CA, provide number of licensees declared under LLC/LLP license filing: How long have you been in business? (If less than 3 years, attach resume for principals and business plan) Have you been involved in any mergers, purchases or acquisitions within the past five years? (If yes, complete Changes, Mergers, Acquisitions supplement) List professional designations, associations or service organizations relating to the services to be insured in which the Applicant (or any officer or principal) belong: REQUESTED COVERAGE: Limits of Liability: $1,000,000/$1,000,000 $2,000,000/$2,000,000 $3,000,000/$3,000,000 $5,000,000/$5,000,000 Other Deductible Per Claim: $5,000 $10,000 $15,000 $20,000 OTHER LIMITS AND DEDUCTIBLES MAY BE AVAILABLE
SECTION II: REVENUE (billing, sales, fees and commissions) 1. List all types of services performed. Attach a separate page if necessary. Current 12 Months Projected 12 Months $ % $ % Benefit Administration & Consulting Administration or Consulting of Health & Welfare plans Administration or Consulting of Pension plans Actuarial Services & Consulting Pension Actuarial Services & Consulting Insurance Company Actuarial Rate Setting Claims adjudication/setting of reserves Third Party Administration Services Third Party Claims Administration: Claims Adjudication Administration & processing for Flex-Spending Accounts (Section 125, Section 105) Claims Audit Services Designing, maintenance of computer program or website Sale/distribution software of computer program or website, not related to TPA services Other ( describe): Life & Health Insurance Sales & Services Financial Services/Products* (Complete Section III) Consulting Services (not listed above) - describe TOTAL 100% 100% 2. Provide approximate percentage of revenues derived from the following types of benefit plans: Must equal 100% of revenues derived from benefit plans Pension Plans % Health & Welfare Plans % Fully or Partially Insured % Self-Insured Single Employer/Corporate Plans Single Employer/Corporate Plans Public/Government Plans Public/Government Plans Multiple Employer Plans/Trusts Multiple Employer Plans Trusts MEWAs PEOs Taft-Hartley (Union) Plans Taft-Hartley (Union) Plans Other (describe): Other (describe): Health & Welfare Plans 3. Are Insurance Carriers used A. M. Best rated A- or better? If, or unrated, complete Supplement B for all plans with carriers less than A- rated 4. Are any Public or Government Plans established less than 10 years? If complete Supplement B for each plan established less than 10 years 5. Has Applicant handled Public or Government Plans for 3 years or more? If complete Supplement B for each plan handled less than 3 years 6. Does any Public or Government Plan have over 5,000 participants? If complete Supplement B for each plan with more than 5,000 participants Defined Contribution Plans 7. Has a favorable IRS determination letter been received on ALL DC Plans? If complete Supplement B on all plans WITHOUT favorable IRS determination letter 8. Are the investment vehicles used for DC plans limited to; Mutual Funds, Fixed Income investments, Equity securities, or Annuities? If '" complete Supplement B for all plans as applicable. 9. Investment Manager or Plan Trustee is fiduciary for SELECTING investments? If complete Supplement B for all plans as applicable 10. Investments are self-directed by plan participants? If complete Supplement B for each plan NOT self-directed N/A N/A N/A N/A N/A N/A N/A N/A
Defined Benefit Plans 11. Funding status is 80% or greater? If complete Supplement B for each plan less than 80% 12. Has a favorable IRS determination letter been received on ALL DB Plans? If complete Supplement B on all plans WITHOUT favorable IRS determination letter 13. Are the investment vehicles used for DB plans limited to; Mutual Funds, Fixed Income investments, Equity securities, or Annuities? If '" complete Supplement B for all plans as applicable 14. Investment Manager or Plan Trustee is fiduciary for SELECTING investments? If complete Supplement B for all plans as applicable N/A N/A N/A N/A Other Specialized Services 15. Do you, or have you formed or managed any: Preferred Provider or similar managed care organization? Insurance captive, rent-a-captive, risk retention group or insurance pooling arrangement? 16. Do you perform appraisals for the valuation of companies? If yes, provide description of types and percentages of revenues. 17. Does the applicant, its partners, directors, officers or employees act as trustee for any clients or non-clients? If yes, provide details: SECTION III: FINANCIAL PLANNING/SECURITIES ACTIVITIES note: If no revenue was listed in Section II Financial Services/Products above, skip this section List all REVENUE from Financial Products and Activities: Current 12 Months Projected 12 Months $ % $ % Stocks and Bonds Mutual Funds Variable Life, Variable Annuities Fixed Annuities Equity Indexed Annuities Unregistered Securities RIA Fees Other ( Describe) If more than 30% of your revenue is from Financial Planning, provide a brief narrative of services provided. List all staff members who require E&O coverage for Financial Services/Products: Type of Securities license held Years of Experience Was any professional license or registration of applicant and/or staff ever denied, suspended, revoked, non-renewed or restricted in any way? If yes, explain on a separate sheet. Are there any pending complaints, pending inquiries or investigations against the applicant and/or staff to FINRA or any other Securities regulatory body? If yes, explain on a separate sheet. SECTION IV: RISK MANAGEMENT PROGRAMS 18. Is there a peer review policy in place? 19. Do you have written documentation, qualifying assumptions or caveat for professional advice and conclusions? 20. Do you always use written contracts or engagement letters, which define your responsibilities to your clients?
21. Describe measures to assure client plans comply with ERISA or other applicable statutes: 22. Do you adjust fees to settle minor errors or omissions? 23. Do you use outside actuarial services? 24. Do you have legal counsel? 25. Do you use an accounting firm in providing services? 26. Do you require the outside firms utilized to carry Professional Liability Insurance? 27. Are annual plan audits performed on those requiring such, as directed by ERISA? If no, please explain: SECTION V: ERRORS AND OMISSIONS INSURANCE In the past five (5) years has the Agency or any Principal, Partner or Officer been denied Professional Liability coverage or refused renewal? This question is not applicable in Missouri. If yes, give reason: Current E&O coverage expiration date: / / Date of first continuous E&O coverage maintained in force without interruption: (very important) / / LIMIT DEDUCTIBLE PREMIUM COMPANY Current Policy Year Previous Policy Year te: this Policy will not apply to claims which any person proposed for this insurance is aware of prior to the effective date of coverage. CHECK ONE: Enclosed is my E&O carrier s loss report(s) covering all claims made during the past five years. There have been no claims made against the firm or any of its partners, directors, officers, employees, brokers or agents in the last five years. Does any partner, director, officer, employee or agent of the Applicant have knowledge or information of any act, error or omission which might reasonably be expected to give rise to a claim? If, attach an explanation. Has the applicant or any of its predecessors in business or subsidiaries or affiliates or any of the past or present partners, owners, officers, sales persons or employees been investigated and/or cited by any regulatory agency for violations arising out of their professional activities? It is agreed that if any applicant or director, officer, manager, member, partner, employee or agent of the applicant for whom coverage is being applied for has knowledge of any information concerning any such fact, circumstance, situation, act, error or omissions, whether or not identified in response to Question 15 or 16, any claims arising therefrom is hereby excluded from coverage under the policy, if issued. It is hereby agreed that the information provided above is true and correct, and is material in deciding whether to issue the above coverage to the Applicant. MUST BE SIGNED AND DATED BY OWNER, PARTNER OR SENIOR OFFICER OF THE AGENCY APPLYING FOR COVERAGE Name: Title: (Print Name) (Print Title) Signature: (Owner, Partner or Senior Officer) Date: (Month/Day/Year) Fraud Warning Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or submits a 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. Arkansas Fraud Warning Colorado Fraud Warning District of Columbia 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. 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 policy holder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from the insurance proceeds shall be reported to the Colorado Division of Insurance with the department of regulatory agencies. 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 an applicant. Florida Fraud Warning 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 of the third degree. Hawaii Warning For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both. Kentucky Fraud Warning 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. Louisiana Applicants Maine Applicants New Jersey Applicants New Mexico Applicants New York Applicants Ohio Applicants Oklahoma Applicants Oregon Applicants Pennsylvania Fraud Warning Tennessee Fraud Warning Virginia Applicants West Virginia Warning 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. 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. Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Any person who knowingly presents a false and 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 penalties. 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 material fact thereto commits a fraudulent insurance act which is a crime, and shall be also subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each violation. 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 guilt of insurance fraud. 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 a false or deceptive statement is guilty of insurance fraud. Any person who knowingly and with intent to defraud or solicit another to defraud an insurer: (1) by submitting an application or; (2) filing a claim containing a false statement as to any material fact may be violating state law. 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. It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purposes of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. 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. 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. RETURN APPLICATION VIA EMAIL: life@citainsurance.com Brown & Brown of California, Inc. dba Cita Insurance Services PO Box 7048 Orange CA 92863-7048 www.citainsurance.com (800) 280-7250 Fax (714) 978-2692 CA Insurance Lic. # 0B02587
SUPPLEMENTAL A CLAIM INFORMATION Instructions: Complete a separate page for each claim. 1. Name of Applicant: 2. Name of Person Involved in Claim: 3. Name of Claimant: 4. Date of Error: 5. Date of Claim: 6. Name(s) of Additional Defendant(s): 7. Name of E&O Carrier: 8. Claim Status: Open In Suit Paid 9. If Paid, a. amount of damages paid: $ b. amount of expenses paid: $ 10. If Open, or in Suit a. claimants settlement demand: $ b. defendants offer for settlement: $ c. E&O carrier Loss Reserve: $ (VERY IMPORTANT) 11. Act, error or omission alleged by claimant: 12. Description of claim and events: 13. What steps have been taken to reduce the likelihood of a reoccurrence of this type of claim? The statements included on this page are true and correct to the best of my knowledge. Signature (Must be signed by Owner or Principal) Date
SUPPLEMENTAL B Plan Description provide the following information for EACH Plan identified on Main Application. Name of plan: Year plan was established: # of Participants: What services are you providing for this plan? Administrative Actuarial Other Describe your services in detail: How long have you been providing services for this plan? years indicate what type of plan and answer applicable questions: 1. Health and Welfare Plan: te: If you are solely providing TPA services for Section 105 (HRA s & HSA s) or Section 125 Plans (FSA s, Cafeteria Plans) you do not need to complete this section for those plans. a. Is the plan: Fully Insured Partially Insured Self Insured b. If fully or partially insured, what insurance carrier(s) provide coverage? c. If self-insured, what insurance company is providing the stop loss or other excess insurance? d. What is the deductible or retention amount of the reinsurance, stop loss or excess insurance? Deductible type: Specific Amount: Aggregate Amount: 2. Public/Government Plan: a. Type of entity: b. City: County: State: c. Continue with question 5. Retirement/Pension Plan questions below. 3. Multiple Employer Plan/MEWAs: a. Who formed the plan? b. How many employers are in the plan? c. Is the plan in endangered or critical status? If yes describe remedial actions being taken:
4. Professional Employer Organization (PEO) : a. Do you only conduct business with PEO's in the states where you have a P&C license? If yes, indicate state(s). b. List the name(s) of the Professional Employer Organization(s) (PEO) that you refer or actively sell to your clients: c. Are these PEO(s) indicated above, licensed, certified, or authorized to do business in the state? d. Describe the nature of the business relationship or services provided on behalf of these PEO's: e. Does your firm sell Human Resources services or products including the sale of Human Resources software? 5. Taft-Hartley (Union) Plan a. What union are you working with and with what industry are they associated? b. City/State: c. Continue with question 6 Retirement/Pension Plan questions below. If you indicated plan is (2) Public/Government Plan, (3) Multiple Employer Plan, (4) Professional Employer Organization (PEO), or (5) Taft-Hartley Plan above, complete the following questions: 6. Retirement/Pension Plan a. Indicate type of plan: a defined contribution plan or a defined benefit plan If DB Plan what is the most current funding status (or funded percentage) % If below 80%, provide a narrative of course of action being taken. b. Has a favorable IRS Plan Determination Letter been received? If, explain why not: c. What investment vehicles are used to fund the plan? Mutual Funds Fixed Income Investments Annuities Equity Securities Employer stock (ESOP) Other (describe) d. Name of product provider(s) of the investment vehicles: e. Who is in the role of fiduciary when selecting the investments for the plan? Plan Sponsor Plan Provider (Investment Mgr.) Other (describe) f. Who is in the role of fiduciary when directing the investments for the plan? Plan Sponsor Plan Participant Applicant (You) Plan Provider (Investment Mgr.) Other (describe) Brown & Brown of California, Inc. dba Cita Insurance Services PO Box 7048 Orange CA 92863-7048 www.citainsurance.com (800) 280-7250 Fax (714) 978-2692 CA Insurance Lic. # 0B02587