Specialty ForeFront Application

Name of Applicant

Company

Officer	First	Initial	Last

Title

Address

Address 1
Address 2
City
State
Zip

Phone

( ) ext.

Fax

( )

E-Mail

Have there been any claims in the past three years?

Yes No

Does any director, officer, employee or partner have information on any act, error, omission or circumstance that may give rise to a claim in the future?

Yes No

How many years has applicant been in business?

Select Coverages Desired:


Directors & Officers	Employment Practices
Fiduciary Liability	Crime
Errors & Omissions	Internet
Workplace Violence	Kidnap / Ransom

Limit of Liability Desired?

Single Limit	Other amount $
Aggregate Limit	Other amount $

Deductible Desired?

Other amount $

Effective Date?

Please describe the industry segment that most clearly describes your business.

Directors & Officers

(Complete only if Directors & Officers Coverage is desired)

D1.

Please indicate the percentage ownership of the company held by Directors & Officers.

Employment Practices
(Complete only if Employment Practices Coverage is desired)
E1.	Please list the number of employees, including seasonal, part-time and independent contractors under your exclusive direction.

E2.	Does the applicant:
	(a) Advise each employee that employment is "at will"?	Yes No
	(b) Maintain policies against Sexual Harassment and Discrimination?	Yes No
	(c) Distribute employee handbook to all employees?	Yes No

Fiduciary Liability

(Complete only if Fiduciary Liability Coverage is desired)

F1.

Are plans reviewed annually to ensure compliance with ERISA?

Yes No

F2.

Are defined benefit plans fully funded as attested to by an actuary?

Yes No

F3.

Within the past three years has any party-in-interest engaged in any prohibited transaction?

Yes No

F4.

Are any plans considered Employee Stock Ownership?

Yes No

F5.

List all plans for which coverage is requested.

	Plan Name	Type	Total Participants	Total Assets
(a)				$
(b)				$
(c)				$
(d)				$
(e)				$

Benefit Plans: (DB) Defined Benefit (DC) Defined Contribution (HW) Health & Welfare

Crime
(Complete only if Crime Coverage is desired)
C1.	Is countersignature of checks required?
		Yes No
C2.	Are bank statements reconciled by someone not authorized to make deposits or withdrawals?
		Yes No

Errors & Omissions
(Complete only if Errors & Omissions Coverage is desired)
O1.	Does any director, officer, partner or employee sit on the board of directors of any client?
		Yes No
O2.	Does the applicant use a written contract with clients?
		Yes No
O3.	Do your contracts contain any of the following:
	(a) Hold harmless or indemnification clauses in your client's favor?	Yes No
	(b) Guarantees or warrantees?	Yes No
	(c) Specific description of the services you will provide?	Yes No
	(d) Payment terms?	Yes No
O4.	Does the applicant have a written procedural manual for employees to follow?
		Yes No

Internet Liability

(Complete only if Internet Liability Coverage is desired)

I1.

Please indicate the average number of page views per month.

I2.

Do any of your Internet sites contain any of the following areas, or sell / make available any of the following products or services?

Check all that apply.
		Pornographic material or other material of a sexually explicit nature?
		Gambling, lotteries or other games of chance?
		Medical records or other healthcare information pertaining to specifically identifiable patients?

Workplace Violence
(Complete only if Workplace Violence Coverage is desired)
V1.	Please indicate the number of employees, including part-time, seasonal and independent contractors under your discretion?

Kidnap / Ransom
(Complete only if Kidnap / Ransom Coverage is desired)
K1.	Please indicate the number of trips per year out of the country.