Description

This product is an application for ERISA fidelity coverage. It should take approximately 10 to 15 minutes to complete the application. After you have completed it, please return to support@bondrepublic.com for processing. ERISA bonds/policies can be quickly issued.

The Travelers ERISA Fidelity Policy automatically insures all ERISA plans of the Sponsor. The Employee Retirement Income Security Act of 1974 (ERISA) requires a plan’s fidelity bond to be no less than 10 of the funds handled by a Trustee/Fiduciary, with a maximum required Bond Limit of $500,000 per plan**. The Limit of Insurance for the Policy should at least equal the sum of the required ERISA coverage limit for each individual plan. The Travelers ERISA Policy contains a unique Inflation Guard feature unless this coverage is removed by endorsement to the policy. This feature automatically provides a limit of insurance, per plan, adjusted at the plan’s fiscal anniversary date, equal to the limit of insurance required by ERISA.

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Travelers Surety

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ERISA Fidelity Coverage Application

Travelers Casualty and Surety Company of America

The term Applicant means the Plan Sponsor and any Employee Benefit Plan proposed for this insurance.

I. AGENCY INFORMATION

Agency Name: ________________________________________________________________

Agency Address: ____________________________________

City: ___________________________________ State: ___ ZIP: _______________

Agency Code: ________________________________________________________________

Producer Name: ___________________________________ Agency Contact: ______________________________

Phone #: ___________________ Fax #: ____________________ Email: __________________________________

II. SPONSOR INFORMATION

Name of Plan Sponsor (Business Name): __________________________________________________________

Sponsor Address: ______________________________________City: _____________ State: ___ ZIP: _________

III. COVERAGE/RATING INFORMATION

1. Proposed Policy Period*: From 12:01 a.m. on to

* Proposed effective date should be within 90 days of the date this Application is completed.

2. Desired Billing Method: Agency Bill or Direct Bill Sponsor Phone #: ________________________________
(Required for Direct Bill)

3. Has the Sponsor or have any of the Applicant’s plans experienced any prior or pending fidelity loss Yes No
(If yes, please forward details to your underwriter.)

4. Has the Sponsor or have any of the Applicant’s plans been declined coverage by another
insurance company (Not applicable to Missouri Applicants.) Yes No

5. Is the Sponsor of any of the Applicant’s plans a Union Yes No
(If yes, please forward details to your underwriter.)

6. Do any of the Applicant’s plans contain Non-Qualifying Assets Yes No
(If yes, please forward details to your underwriter.)

7. Do any of the Applicant’s plans contain Employer Securities Yes No
(If yes, please forward details to your underwriter.)

8. Does the Applicant wish to have the individual plan names listed on the policy Yes No
(If yes, please list the plan names below. Attach an additional sheet if necessary.)

Plan Name:

________________________ Total Assets of Plan #1: _________________ x .10 = ___________________ Plan #1 Limit **

________________________ + Total Assets of Plan #2: _________________ x .10 = ___________________ Plan #2 Limit **

________________________ + Total Assets of Plan #3: _________________ x .10 = ___________________ Plan #3 Limit **

= Limit Requested: ______________________ should equal the sum of the Plan Limits above
(Plan #1 + Plan #2 + Plan #3, etc.)
EFP-14101 Rev. 03-14 Page 1 of 3
2014 The Travelers Indemnity Company. All rights reserved.

Notes: The Travelers ERISA Fidelity Policy automatically insures all ERISA plans of the Sponsor. The Employee Retirement Income
Security Act of 1974 (ERISA) requires a plan’s fidelity bond to be no less than 10 of the funds handled by a Trustee/Fiduciary, with a
maximum required Bond Limit of $500,000 per plan**. The Limit of Insurance for the Policy should at least equal the sum of the
required ERISA coverage limit for each individual plan. The Travelers ERISA Policy contains a unique Inflation Guard feature unless
this coverage is removed by endorsement to the policy. This feature automatically provides a limit of insurance, per plan, adjusted at
the plan’s fiscal anniversary date, equal to the limit of insurance required by ERISA.

**ERISA may require a plan coverage limit to exceed $500,000 if a plan holds non-qualifying assets or employer securities. Coverage
limits above $500,000 are available for these plans, but require prior Company approval.

IV. COMPENSATION NOTICE

Important Notice Regarding Compensation Disclosure

For information about how Travelers compensates independent agents, brokers, or other insurance producers, please
visit this website: http://www.travelers.com/w3c/legal/Producer_Compensation_Disclosure.html

V. FRAUD WARNINGS

Attention: Insureds in Alabama, Arkansas, D.C., Maryland, New Mexico, and Rhode Island
Any person who knowingly (or willfully in MD) presents a false or fraudulent claim for payment of a loss or benefit or
who knowingly (or willfully in MD) presents false information in an application for insurance is guilty of a crime and may
be subject to fines and confinement in prison.

Attention: Insureds in Colorado
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 Agencies.
Attention: Insureds in Florida
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.

Attention: Insureds in Kentucky, New Jersey, New York, Ohio, and Pennsylvania
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. (In New York, the civil penalty is not to exceed five thousand dollars
($5,000) and the stated value of the claim for each such violation.)
Attention: Insureds in Louisiana, Maine, Tennessee, Virginia, and Washington
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.
Attention: Insureds in Oregon
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly
presents false information in an application for insurance may be guilty of a crime and may be subject to fines and
confinement in prison.

Attention: Insureds in Puerto Rico
Any person who knowingly and with the intention of defrauding presents false information in an insurance application,
or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or
presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be
sanctioned for each violation with the penalty of a fine of not less than five thousand dollars ($5,000) and not more than
ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should
aggravating circumstances be present, the penalty thus established may be increased to a maximum of five (5) years; if
extenuating circumstances are present, it may be reduced to a minimum of two (2) years.

EFP-14101 Rev. 03-14 Page 2 of 3
2014 The Travelers Indemnity Company. All rights reserved.

VI. SIGNATURE SECTION

THE UNDERSIGNED OFFICER OF THE APPLICANT (AUTHORIZED REPRESENTATIVE) DECLARES THAT TO THE
BEST OF HIS/HER KNOWLEDGE AND BELIEF, THE STATEMENTS SET FORTH IN THIS APPLICATION FOR
INSURANCE AND MATERIAL SUBMITTED THEREWITH ARE TRUE AND COMPLETE. SUCH APPLICATION AND
MATERIALS WILL BE RELIED ON BY TRAVELERS AND BE THE BASIS OF THE INSURANCE. IN NORTH
CAROLINA, IF THE BOND APPLIED FOR STATES THAT THE APPLICATION CONSTITUTES PART OF THE BOND,
SUCH STATEMENT SHALL NOT APPLY TO THIS APPLICATION. IF ANY INFORMATION IN THIS APPLICATION
CHANGES PRIOR TO THE INCEPTION DATE OF THE BOND, THE APPLICANT WILL NOTIFY TRAVELERS OF
SUCH CHANGES AND TRAVELERS MAY MODIFY OR WITHDRAW ANY OUTSTANDING QUOTATION.
TRAVELERS IS AUTHORIZED TO MAKE INQUIRY IN CONNECTION WITH THIS APPLICATION. THE SIGNING OF
THIS APPLICATION DOES NOT BIND TRAVELERS TO OFFER, NOR THE APPLICANT TO PURCHASE, THE
INSURANCE.

ELECTRONICALLY REPRODUCED SIGNATURES WILL BE TREATED AS ORIGINAL.

Signature*: Officer of Applicant Name (Printed)
(Authorized Representative)

Title Date

VII. PRODUCER INFORMATION (ONLY REQUIRED IN FLORIDA, IOWA, AND NEW HAMPSHIRE):

Producer Signature* Producer Name (Printed)

Agency Name Agency Code License Number

*IF YOU ARE ELECTRONICALLY SUBMITTING THIS APPLICATION TO TRAVELERS, APPLY YOUR ELECTRONIC
SIGNATURE TO THIS FORM BY CHECKING THE ELECTRONIC SIGNATURE AND ACCEPTANCE BOX BELOW.
BY DOING SO, YOU HEREBY CONSENT AND AGREE THAT YOUR USE OF A KEY PAD, MOUSE, OR OTHER
DEVICE TO CHECK THE ELECTRONIC SIGNATURE AND ACCEPTANCE BOX CONSTITUTES YOUR SIGNATURE,
ACCEPTANCE, AND AGREEMENT AS IF ACTUALLY SIGNED BY YOU IN WRITING AND HAS THE SAME FORCE
AND EFFECT AS A SIGNATURE AFFIXED BY HAND.

AUTHORIZED REPRESENTATIVE’S ELECTRONIC SIGNATURE AND ACCEPTANCE

PRODUCER’S ELECTRONIC SIGNATURE AND ACCEPTANCE

EFP-14101 Rev. 03-14 Page 3 of 3
2014 The Travelers Indemnity Company. All rights reserved.

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