Fiduciary Liability Insurance Application
Your Name:
E-mail Address:
Name of firm:
Street address:
Other Comments
Are there any other kinds of insurance you need (e.g.,
Directors & Officers, Employee Dishonesty, etc.)?
Please list them, along with any comments or questions you
may have.
We would especially like your feedback on this form's ease of use.
Why you need it:
Prudent Person Rule
ERISA fiduciary law that requires all fiduciaries to conduct the business of the plan with prudence and care.
Any fiduciary violating this law is liable to the plan and its participants for all losses.
Under provisions of the Employee Retirement Income Security Act of 1974 (ERISA), individuals who administer retirement, group health, savings or other employee benefit plans must maintain a fidelity bond, and may be responsible for losses that arise from any breaches of their fiduciary responsibilities or duties.
The complex laws and regulations have spawned a growing number of ERISA related lawsuits.
According to the Wall Street Journal, ERISA lawsuits grew by 35% to 10,536 from 1989 to 1993 and it has only gotten worse since then.
If you are an owner or officer who makes decisions about your company's 401(k) plan or other qualified employee benefit plan(s), odds are, your personal assets are at risk!
Please insert limit desired
if not shown above: $
Official Name(s) of employee benefit trust or plan
(as it appears on the Form 5500) Annual Contribution, or, for welfare plans, annual expense Asset Value
(All premium estimates are offered contingent on
receipt/acceptable review of original completed application.)
Number of Participants
Pension Plan Investment
Administrator: (i.e.Smith Barney,
The Principal, XYZ Bank, etc.)
Employer Identification Number (EIN):
(Dept. of Treasury/DOL Form 5500 or
Form 5500 C/R, pg. 1 b.) (7 digits)
SIC/Business Code: (Dept. of Treasury/DOL
Form 5500 or Form 5500 C/R, pg. 1 d.) (4 digits)
Nature of Your Business: (i.e. Auto Dealer, machine parts manufacturer, consulting engineers, etc.)
Would like a premium estimate
on coverage amount:
City
State
Zip Code
Phone
Fax
Employer (Plan Sponsor) Name
Employer (Plan Sponsor) Address
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None of the information in this web site should be construed as legal or insurance advice.
All forms, policies, terms, information and procedures should be reviewed by your legal
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