BF&M STEP Proposal 2018 · Template Trust document 2. ... attach resume(s) ... $bfm.bm$!!!!! BF&M I. GENERAL INFORMATION =i_i I Non- of Applicant: Mailing Address:

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BF&M%LIFE%INSURANCE%COMPANY%LIMITED%P.O.$Box$HM$1007,$Hamilton$HM$DX,$Bermuda$$T:$+1$441$295$5566,$F:$+1$441$292$8831,$W:$bfm.bm$

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TRUSTEE,%RECEIVER,%BF&M%GENERAL%INSURANCE%COMPANY%LIMITED%PROFESSIONAL%LIABILITY%POLICY%APPLICATION$

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TRUSTEE, RECEIVER, BF&M GENERAL INSURANCE COMPANY LIMITEDPROFESSIONAL LIABILITY POLICY APPLICATION

NOTICE: THE LIMITS OF LIABILITY AVAILABLE TO PAY JUDGMENTS OR SETTLEMENTS SHALL BE REDUCEDBY AMOUNTS INCURRED FOR LEGAL DEFENSE AND CLAIMS EXPENSES. FURTHER NOTE THAT AMOUNTSINCURRED FOR LEGAL DEFENSE AND CLAIMS EXPENSES SHALL BE APPLIED AGAINST THE RETENTIONAMOUNT. IF THE POLICY IS ISSUED. SOME COVERAGES WILL BE ON A CLAIMS-MADE AND REPORTED BASIS.

"You," 'Your" or "Applicant" refer individually and collectively to the Applicant, subsidiaries, persons, entities, and theauthorized agent of all person(s) and entity(s), proposed for this insurance. Some sections of the Application may not applyto You. I f this is the case, please mark 'not applicable' (N/A). 'Proposed policy" shall mean a TRUST Assure policyproviding professional liability coverage for professional services as defined. In the event You need more space to fullyanswer a question, please attach separate sheet(s) to this Application with Your full answer.

Before continuing. please attach copies of:

1. T e m p l a t e Trust document

2. L o s s e s notified to you during the past three (3) years.

Resumes of all trustees, guardians of the estate or receivers if an individual or partnership is the Applicant. If acorporation or other entity is the Applicant, attach resume(s) of the significant provider(s) of services, and copiesof any services brochures, contracts or agreements, and any advertising materials.

4. O t h e r information that You believe will better help us understand Your services.

BF&M LIFE INSURANCE COMPANY LIMITED

P.O. Box HM 1007, Hamilton HM DX, Bermuda T: +1 441 295 5566, F: +1 441 292 8831, W: bfm.bm

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I. G E N E R A L INFORMATION

=i_i I Non- o f Applicant:

Mailing Address:

. . . .STEP Identification Number

Applicant entity type: • Individual • Corporation • Partnership • Other (describe):

Applicant services (hereinafter any service selectedshall be referred to as "Professional Services"):

• Trustee Services• Guardian of the Estate Services

• Receiver Services• Corporate Services

Applicant Telephone: Country of incorporation orformation:

Applicant Date Established: No. of Employees:

Risk Manager/Contact: Contact E-Mail Address:

Requested Effective Date: Requested Retroactive Date:

Do any of your Trust,Guardianship, Estate orReceivership agreements involveTransnational Registration?

• Yes • No

If yes, kindly indicate how manyagreements are involved.



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Please list the Professional Service(s), Country the laws of the trust are applicable to and Full Name(s) in whichthey are registered?

Professional Service C o u n t r y F u l l Name

Aggregate Limit Requested:

■ BMD ■ BMD

Options: ■ BMD ■ BMD

■ BMD ■ Other BMD

BF&M LIFE INSURANCE COMPANY LIMITEDP.O. Box HM 1007, Hamilton HM DX, Bermuda T: +1 441 295 5566, F: +1 441 292 8831, W: bfm.bm

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250,000

1,000,000

5,000,000

500,000

2,500,000

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II. ASSETS UNDER MANAGEMENT INFORMATION

(Fiscal year basis) Prior Year 2017 Current Year 2018 Projected Next Year

Cash S $ S

Stocks and Bonds S $ S

Real Estate S . $ . S

Insurance S $ S

Other S $ S

TOTAL $ $ $If a business is under management byprovide corporate services, kindly indicate:

You as part of the trust. guardianship estate or receivership and for whom you

Total U.S. Revenue S $ S

Total non-U.S_ Revenue S $ S

Net Income S $ S

Current Assets. .

S $ S

Current Liabilities.

S

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$ S

Total Assets S $ S

Total Debt S $ S

Identify the name and describe the nature of any on-going business:



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Ill. R E V E N U E ALLOCATION Estimate Your [oral annual projected worldwide revenue for the next

•fiscal year for each:

Professional services Projected Annuai Revers u es

I. of Application (trust services,services or corporate services, $

■ Professional services selected in Sectionguardianship services, receivershipas applicable)

Additional Sources of RevenuePlease note that this is for information purposes only as cover for these activities is provided under a separatepolicy:FOR ACCOUNTANTS ONLY FOR LAWYERS ONLY

Audit accountancy and company tax $ Real Estate Conveyancing $

Taxation only $ Litigation $

Management consultancy $ Commercial matters $

Consultancy only $Any others, please give details:

Any others, please give details:$

$

TOTAL: $ TOTAL: $



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IV. LICENSING AND EMPLOYEES

1. Have You received any training or have You received any certification orlicensing for any of the Professional Services? Yes No• •

If "yes," who has provided You with the training or who has issued You withthe certification or a license?

2. Do You employ any employees to assist You in performing ProfessionalServices? Yes No• •

If "yes", how many do You employ?

V. ASSETS UNDER MANAGEMENT of any trust, guardian estate or receivership identified in Section 1

1. Is there any co-mingling of the assets of any trust. estate or receivershipidentified in this Application with the assets You own? Yes No• •

If "yes," explain:

2. Are You a beneficiary or do You have any ownership interest in any assets ofany trust, guardianship estate or receivership identified in this Application? Yes No• •

If "yes," explain:

VI. CLIENT FUNDS

1. Do You handle the collection of any funds on behalf of any trust. guardianshipestate or receivership identified in this Application (e.g., rent collection, deposits,etc.)?

Yes No• •

2. Do You employ legal counsel, an accountant or other professionals (e.g.,investment advisor, stock broker, financial analyst, etc.) to advise and assist Youin providing Professional Services?

Yes No• •

If "yes," please identify:

3. Do You have discretionary authority in investment of the assets containedwithin any Trust, Estate or Receivership identified in this Application? Yes No• •

If "yes," please explain:

4. Are you an investment advisor? Yes No• •

If "yes", please provide a copy of your ADV form.

5. Is an independent Certified Accountant used to prepare and file financialstatements and tax forms for any trust, guardianship estate or receivershipidentified in this Application?

Yes No• •



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6. D o You have a current loan with, or have You ever received a loan from, anytrust, guardianship estate or receivership identified in this Application? • Yes • No

If "yes,' please explain:

7. Have any distributions been made during the past twelve (12) months or areany distributions anticipated in the next twelve (12 months) from any trust,estate or receivership identified in this Application?

• Yes • No


VII. HISTORICAL INFORMATION

1. Have You, or any director, officer, partner, or employee providing services onYour behalf ever been subject to disciplinary proceeding arising out ofprofessional services activities?

• Yes • No


2. A r e You aware of any actual or alleged fact, circumstance. situation, error oromission, or issue which might give rise to a claim against You under theproposed policy?

• Yes • No


3. H a s any insurance carrier ever cancelled or non-renewed a policy that providedthe same or similar coverage as the proposed policy? • Yes • No


4. Has any claim, demand, lawsuit, arbitration, litigation, bankruptcy,administrative proceeding or regulatory proceeding been made or initiatedagainst You, that might have given rise to a claim under the proposed policy ifthe same or similar insurance coverage was in force?

• Yes • No


5. H a s there been or is there now pending any litigation or claim against You orany civil, criminal, administrative or regulatory action or proceeding against Youarising out of the rendering or failure to render professional services?

• Yes • No


6. What is the first date of continuous claims-made coverage for professionalservices liability for You? DDIIVIM M.IYYYY • NiA


P.O. Box HM 1007, Hamilton HM DX, Bermuda T: +1 441 295 5566, F: +1 441 292 8831, W: DIM.DM

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7. D o You currently have or have You had, over the past five (5) years, any policyproviding coverage for professional services liability?

If "yes , kindly attach a separate document which lists for each policy: (a)insurer's name; (b) the policy period; (c) the policy limits; (d) the retention:and (e) the retroactive date.

• Yes • No

8. Have You reported any occurrences, claims or losses to any insurer in the pastfive (5) years that provided the same or similar insurance to the proposedpolicy?

• Yes • No

If "yes," please attach a separate document with respect to each such occurrences, claim or loss providing:

(a) description; (b) the name of the insurer and policy; (c) the amount of damages, expenses or other losssuffered

as a result of occurrences, claim or loss; (d) and the amount paid by the insurer to whom notice was provided (ifany)

VIII, ADDITIONAL DOCUMENTS AND INFORMATION INCORPORATED BY REFERENCE

ALL WRITTEN STATEMENTS. MATERIALS OR DOCUMENTS FURNISHED TO THE INSURER INCONJUNCTION WITH THIS APPLICATION. REGARDLESS OF WHETHER SUCH DOCUMENTS AREATTACHED TO THE POLICY, ARE HEREBY INCORPORATED BY REFERENCE INTO THIS APPLICATIONAND MADE A PART HEREOF, INCLUDING WITHOUT LIMITATION ANY SUPPLEMENTAL APPLICATIONSOR QUESTIONNAIRES.



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BF&MIX. L E G A L NOTICE AND SIGNATURES

BEFORE YOU SIGN THIS APPLICATION. READ THESE NOTICES CAREFULLY AND DISCUSS WITH YOURBROKER OR AGENT IF YOU HAVE ANY QUESTIONS.FOR THE PURPOSES OF THIS APPLICATION, THE UNDERSIGNED DULY AUTHORIZED REPRESENTATIVE OFALL PERSON(S) OR ENTITIES PROPOSED FOR THIS INSURANCE DECLARES THAT, TO THE BEST OF HIS/HEFKNOWLEDGE AND BELIEF, AFTER REASONABLE ENQUIRY, THE STATEMENTS IN THIS APPLICATION. ANC.IN ANY ATTACHMENTS, ARE TRUE AND COMPLETE.THE UNDERSIGNED DULY AUTHORIZED REPRESENTATIVE AGREES THAT IF THE STATEMENTS ANDINFORMATION SUPPLIED ON THIS APPLICATION OR INCORPORATED BY REFERENCE SHALL CHANGEBETWEEN THE DATE OF THIS APPLICATION AND THE EFFECTIVE DATE OF THE INSURANCE, HE/SHE(UNDERSIGNED) SHALL, IN ORDER FOR THE INFORMATION TO BE ACCURATE ON THE EFFECTIVE DATE OFTHE INSURANCE, IMMEDIATELY NOTIFY THE INSURER OF SUCH CHANGES, AND THE INSURER MA'rWITHDRAW OR MODIFY ANY OUTSTANDING QUOTATIONS AND/OR AUTHORIZATIONS OR AGREEMENTS TOBIND THE INSURANCE.THE SIGNING OF THIS APPLICATION DOES NOT BIND THE APPLICANT OR THE INSURER TO COMPLETE THEINSURANCE, BUT IT IS AGREED THAT THIS APPLICATION AND ANY INFORMATION INCORPORATED BYREFERENCE HERETO, SHALL BE THE BASIS OF THE CONTRACT SHOULD A POLICY BE ISSUED, AND ISINCORPORATED INTO AND IS PART OF THE POLICY.SHOULD INSURER ISSUE A POLICY, APPLICANT AGREES THAT SUCH POLICY IS ISSUED IN RELIANCE UPONTHE TRUTH OF THE STATEMENTS AND REPRESENTATIONS IN THIS APPLICATION OR INCORPORATED BYREFERENCE HEREIN. ANY MISREPRESENTATION, OMISSION, CONCEALMENT OR INCORRECT STATEMENTOF A MATERIAL FACT, IN THIS APPLICATION, INCORPORATED BY REFERENCE OR OTHERWISE, SHALL BEGROUNDS FOR THE RESCISSION OF ANY POLICY ISSUED.NOTICE TO APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANYINSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OFCLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR, CONCEALS, FOR THE PURPOSE OFMISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENTACT, WHICH IS A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.



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DECLARATION

The undersigned is the Applicant or a duly authorized representative of the Applicant and hereby acknowledges thatreasonable enquiry has been made to obtain the answers herein which are true, correct, and complete to his/her bestknowledge and belief.

Signed(Duly authorized representative, by and on behalf of the Applicant!

Date

Title

Organization(Must be signed by an authorized officer)

(Organization's seal)

' i tness(Duly authorized representative, by and on behalf of the Applicant)



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Documents

BF&M STEP Proposal 2018 · Template Trust document 2. ... attach resume(s) ... $bfm.bm$!!!!! BF&M I. GENERAL INFORMATION =i_i I Non- of Applicant: Mailing Address: