ࡱ>  bjbj>> ;pTpT( ( 8D>>L%Z@&,l&\<<<<<<<$@B^#=Q*%"%Q*Q*#==...Q*~\<.Q*\<..V\6@ 7@^(j+66 H<>0>>6x.D-r.D 7 7.D47&\'.'|r(&&&#=#=w.X&&&>>Q*Q*Q*Q*.D&&&&&&&&&( H: EMPLOYEE BENEFITS LIABILITY APPLICATION THE INFORMATION BEING REQUESTED IS FOR A CLAIMS-MADE POLICY. IT IS IMPORTANT THAT YOU READ ALL OF THE PROVISIONS OF YOUR POLICY CAREFULLY. Answer each question on behalf of all entities seeking insurance coverage, unless specifically requested otherwise. An Additional Information section is provided at the end of this document for any information that exceeds the space provided. GENERAL INFORMATION Proposed First Named Insured & Other Named Insured(s):  FORMTEXT      Today's Date:  FORMTEXT      Mailing Address:  FORMTEXT      Type of Legal Entity:  FORMTEXT      Proposed Effective Date (mm/dd/yyyy):  FORMTEXT      Proposed Expiration Date (mm/dd/yyyy):  FORMTEXT      Date Business Started:  FORMTEXT       EMPLOYEE BENEFIT INFORMATION 1. Proposed retroactive date: FORMTEXT       2. Deductible: FORMTEXT       3. Number of employees: FORMTEXT       4. Each employee limit of insurance: FORMTEXT       Aggregate limit of insurance: FORMTEXT        5. Losses and known acts, errors, or omissions, which may result in claims being made under this insurance in the last 5 years (If none, please identify  None ): FORMTEXT        6. Employee benefits provided: Please mark  I for insured plans and mark  S for self-funded or self-insured plans.  FORMTEXT  Group life FORMTEXT  Unemployment insurance FORMTEXT  Group accident FORMTEXT  Social security benefits FORMTEXT  Group health FORMTEXT  Workers compensation FORMTEXT  Group LTD FORMTEXT  Disability benefits (required by states) FORMTEXT  Group profit sharing plans FORMTEXT  Stock subscription plans* FORMTEXT  Pension plans*Please explain eligibility for stock subscription plans. 7. Name and title of the person responsible for the management of your employee benefit program: a. Number of years in this position: FORMTEXT      b. Number of years experience in the administration of benefits plans: FORMTEXT       8. Are all personnel who counsel employees about benefits familiar with the details of the program identified in question 6?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 9. Are all personnel who counsel employees about benefits familiar with COBRA requirements?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 10. Are all programs in compliance with COBRA requirements?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If no, please explain: FORMTEXT        11. Do you administer any benefit plans for others?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, please explain: FORMTEXT        12. Have you rejected the Workers Compensation Acts in any state?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, please identify what state and describe if you offer an alternative benefit packages: FORMTEXT        13. For optional employee benefits, are rejections, either signed or electronic, required and kept on file?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Your employee benefits liability policy does not apply to taxes, fines, or penalties imposed under the Internal Revenue Code or any similar state or local law or loss or damages arising out of the imposition of such taxes, fines, or penalties. For information about how Travelers compensates independent agents, brokers, or other insurance producers, please visit this website:  MacroButton "FollowLink" HYPERLINK "http://www.travelers.com/w3c/legal/Producer_Compensation_Disclosure.html" \t "window" http://www.travelers.com/w3c/legal/Producer_Compensation_Disclosure.html   If you prefer, you can call the following toll-free number: 1-866-904-8348. Or you can write to us at Travelers, Enterprise Development, One Tower Square, Hartford, CT 06183. This application, including any material submitted in conjunction with the application or any renewal, does not amend the provisions or coverages of any insurance policy or bond issued by Travelers. It is not a representation that coverage does or does not exist for any particular claim or loss under any such policy or bond. Coverage depends on the facts and circumstances involved in the claim or loss, all applicable policy or bond provisions, and any applicable law. Availability of coverage referenced in this document can depend on underwriting qualifications and state regulations. FRAUD STATEMENTS Attention Applicants in the Following Jurisdictions: ARKANSAS, DISTRICT OF COLUMBIA., MARYLAND, NEW MEXICO, AND RHODE ISLAND: Any person who knowingly (and willfully in D.C. and MD) presents a false or fraudulent claim for payment of a loss or benefit or who knowingly (and willfully in D.C. and MD) presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. 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. 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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.) 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. SIGNATURES Authorized Representative Signature*: X FORMTEXT      Authorized Representative Name:  FORMTEXT      Date:  FORMTEXT      Producer Signature*: X FORMTEXT      State Producer License Number (required in FL):  FORMTEXT      Date:  FORMTEXT      Agency:  FORMTEXT      Agency Contact:  FORMTEXT      Agency Phone Number:  FORMTEXT      * If you are electronically submitting this document, apply your electronic signature to this form by checking the Electronic Signature and Acceptance box below. By doing so, you 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.  FORMCHECKBOX  Electronic Signature and Acceptance Authorized Representative  FORMCHECKBOX $&hj~ѷe緢Ge緢;jh h0:5B* CJOJQJU^JaJph=jh hzX0J@B* CJU^JaJmHnHphu;j?h h0:5B* CJOJQJU^JaJph)h h0:0J@B* CJ^JaJph2jh h0:0J@B* CJU^JaJph*h hgS5B*OJQJ\]^Jph/h hgSB*CJOJQJ\]^JaJph(hġơzOkd$$IfsF!#*LHt t0    44 sapyt $IfgdgSl ¡ z|ǨǐzeGǨǐe;jSh h0:5B* CJOJQJU^JaJph)h h0:0J@B* CJ^JaJph*h hgS5B*OJQJ\]^Jph/h hgSB*CJOJQJ\]^JaJph=jh hzX0J@B* CJU^JaJmHnHphu2jh h0:0J@B* CJU^JaJph;j'h h0:5B* CJOJQJU^JaJphĢƢȢҢԢ 02FǨǐ{]Ǩǐ{?Ǩǐ{;jgh h0:5B* CJOJQJU^JaJph;j;h h0:5B* CJOJQJU^JaJph)h h0:0J@B* CJ^JaJph/h hgSB*CJOJQJ\]^JaJph=jh hzX0J@B* CJU^JaJmHnHphu2jh h0:0J@B* CJU^JaJph;jdžh h0:5B* CJOJQJU^JaJph֢آ0XOkd$$IfsF!#*LHt t0    44 sapyt $IfgdgSl FHJTVǨǐ{]ǨǐF+F5jhgSh~0J5@B*CJU^JaJph,hgSh~0J5@B*CJ^JaJph;jOh h0:5B* CJOJQJU^JaJph)h h0:0J@B* CJ^JaJph/h hgSB*CJOJQJ\]^JaJph=jh hzX0J@B* CJU^JaJmHnHphu2jh h0:0J@B* CJU^JaJph;jۈh h0:5B* CJOJQJU^JaJphbdb[TOOgdgS<gdn$xgd@WkdÉ$$IfsFQ *LxD t0    44 sapyt bd$nprȱȱȒ{h{Q{72jhyh@W0J@B* CJU^JaJph,hgSh, 0J5@B*CJ^JaJph%h<hI0J@B*^JaJph,hgShI0J5@B*CJ^JaJphU8jhzXhxB*CJOJQJU^JaJph,hgSh~0J5@B*CJ^JaJph5jhgSh~0J5@B*CJU^JaJph8j{hzXhxB*CJOJQJU^JaJph Electronic Signature and Acceptance  Producer ADDITIONAL INFORMATION This area may be used to provide additional information to any question. Please reference the question number.  FORMTEXT           CP-4391 Rev. 04-12 2012 The TravelersdpLMNO|^|gdIp$a$gd4gd( !d(xgdMpgdgSxgdn$1$s$d%d&d'dNOPQ]^sa$gdgSrֹع/ж}y}y}y}yk`OkOMOU h,ah2+CJOJQJ^JaJh,ah2+CJaJh2+CJOJQJ^JaJh jh U)hgSh0J@B*CJ^JaJph7jhzX0J@B* CJU^JaJmHnHphu2jhyh@W0J@B* CJU^JaJph3jchyh@W5B* CJU^JaJph)hyh@W0J@B* CJ^JaJph Indemnity Company. All rights reserved. Page  PAGE 2 of  NUMPAGES 2 CP-4391 Rev. 04-12 2012 The Travelers Indemnity Company. All rights reserved. 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