ࡱ>  XZMNOPQRSTUVW#` Tbjbjmm ^w_0 0 0 0 0 0 0 D 0008hL D fO"(FFF6 3KKKKKKK6QhSlK0 "K0 0 FFNN0 F0 FKK0 0 F oHι09F#D(OTfOb T} T T0 {yl$ {{{KKaX{{{fOD D >KLD D KLD D D 0 0 0 0 0 0 N  Financial Institutions Select"! Insurance Policy and Financial Institution Select Bond Application   FORMCHECKBOX Financial Institutions SelectTM Insurance Policy (herein called "policy") FORMCHECKBOX  New or  FORMCHECKBOX  Renewal of the Insurereffective as of 12:01 a.m. on FORMTEXT       FORMCHECKBOX Financial Institution Select Bond (herein called "bond") FORMCHECKBOX  New or  FORMCHECKBOX  Renewal of the Underwritereffective as of 12:01 a.m. on FORMTEXT      Wherever this Application uses the word Insurer, it is referring to the word Underwriter as used in the bond.A. General Information  Complete for all coverages1. Applicant  For the purposes of the policy, applicant means the Company, subsidiaries and directors and officers, including any such organization as a debtor in possession under United States bankruptcy law or an equivalent status under the law of any other country, and for the purposes of the bond, the insured. Provide the following information for each applicant (other than directors and officers) proposed for coverage. If more space is necessary, provide an attachment.Name of ApplicantDate Est.Owned by% OwnedDescription of Business FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      % FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      % FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      % FORMTEXT      2. Notices for the policy required to be given to the applicant named first shall be addressed to: FORMTEXT      3. Principal Address FORMTEXT      (No.)(Street)(City)(County)(State)(Zip Code)Is this address within the corporate limits of the city above? FORMCHECKBOX  Yes  FORMCHECKBOX  NoWeb Address: FORMTEXT      4. The applicant named first is a:Commercial Bank: FORMCHECKBOX  National FORMCHECKBOX  StateSavings & Loan Association/Federal Savings Bank (FSB): FORMCHECKBOX  Federal FORMCHECKBOX  StateSavings Bank:  FORMCHECKBOX Credit Union:  FORMCHECKBOX Other:  FORMCHECKBOX  FORMTEXT      NOTICE OF DISCLOSURE FOR AGENT & BROKER COMPENSATION If you want to learn more about the compensation Zurich pays agents and brokers visit:  HYPERLINK "http://www.zurichnaproducercompensation.com" http://www.zurichnaproducercompensation.com or call the following toll-free number: (866) 903-1192. This Notice is provided on behalf of Zurich American Insurance Company and its underwriting subsidiaries. 5. Are deposits insured by: FORMCHECKBOX  FDIC FORMCHECKBOX  NCUSIF FORMCHECKBOX  Other (specify) FORMTEXT      6. a. Date of last regulatory examination: FORMTEXT      Name of regulator FORMTEXT      b. Has there been compliance with all recommendations and criticisms from the last exam? FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf no, provide full details by attachment.7. Has any applicant, as defined in A 1 above, received a cease and desist order or entered into any special situation agreement or memorandum of understanding or similar written agreement with, or been the subject of any other administrative, supervisory or compliance sanction, fine, penalty, action or order, by any regulatory agency in the last 3 years, or, if this is a renewal of the bond or policy, since the date of the last application or proposal form? FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf no, provide full details by attachment.8. Has any applicant, as defined in A 1 above, been examined or investigated by the SEC or NASD or are any examinations or investigations proposed? FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf yes, provide full details by attachment.9. Has there been any change in the board of directors or senior management of the Company or subsidiaries, as defined in A 1 above, (other than death or retirement) in the last 3 years, or, if this is a renewal of the bond or policy, since the date of the last application or proposal form? FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf yes, provide full details by attachment.10. a. Has the applicant originated any subprime* mortgage loans in the past 3 years? FORMCHECKBOX  Yes  FORMCHECKBOX  Nob. Has the applicant invested in any subprime* mortgage loans or securities backed by such loans in the past 3 years? FORMCHECKBOX  Yes  FORMCHECKBOX  Noc. Has the applicant invested in any commercial mortgage backed securities, credit default swaps, collateralized debt obligations, asset backed securities, auction rate securities, or non-agency residential mortgage backed securities in the past 3 years? FORMCHECKBOX  Yes  FORMCHECKBOX  No*For the purposes of this question, subprime means anything less than A paper, a loan-to-value ratio of >100%, or a loan where a borrower's FICO score was less than 640 at origination.If yes to any of the above, provide details by attachment, by year, including total amount, in dollars and item count, of subprime loans, the subprime loans currently in default and the subprime loans in foreclosure and separately, total subprime loans invested in, the type(s) of investment(s) (e.g. mortgage backed securities) and the status of the investment(s).11. Average FICO score on all loans: FORMTEXT      B. For the Financial Institutions Select Insurance Policy, complete the following:NOTICE THE LIABILITY COVERAGE PARTS, IF PURCHASED, ARE ON A CLAIMS MADE AND REPORTED BASIS AND COVER ONLY CLAIMS FIRST MADE AGAINST THE INSUREDS DURING THE POLICY PERIOD OR THE EXTENDED REPORTING PERIOD OR RUN-OFF COVERAGE PERIOD, IF EXERCISED, AND REPORTED TO THE INSURER AS REQUIRED BY THIS POLICY. THE LIMITS OF LIABILITY AND RETENTION SHALL BE REDUCED BY AMOUNTS INCURRED AS DEFENSE COSTS. PLEASE REVIEW THE POLICY CAREFULLY AND DISCUSS THE COVERAGE HEREUNDER WITH YOUR INSURANCE AGENT OR BROKER AND YOUR ATTORNEY.1. Ownership FORMCHECKBOX  Stock FORMCHECKBOX  Mutual2. If the applicant is a stock corporation:a. It is a: FORMCHECKBOX  Private Corporation FORMCHECKBOX  Public Corporationb. Provide the:Trade Symbol: FORMTEXT      Exchange: FORMTEXT      c. Total number of shareholders: FORMTEXT      d. Total number of shares outstanding: FORMTEXT      e. Total number of shares owned directly or beneficially by directors and officers FORMTEXT      f. Provide a list of name and percent of stock owned by any shareholder(s) holding directly or beneficially 10% or more of the common stock of the applicantShareholderPercentageShareholderPercentage FORMTEXT       FORMTEXT      % FORMTEXT       FORMTEXT      % FORMTEXT       FORMTEXT      % FORMTEXT       FORMTEXT      % FORMTEXT       FORMTEXT      % FORMTEXT       FORMTEXT      % FORMTEXT       FORMTEXT      % FORMTEXT       FORMTEXT      %3. Identify the services any applicants currently offer, including those using third parties, and provide total revenue, per the annual report, derived from the service.ServiceRevenueRevenue less than 1%a. Discount brokerage operation$ FORMTEXT       FORMCHECKBOX  Yes  FORMCHECKBOX  Nob. Loan services$ FORMTEXT       FORMCHECKBOX  Yes  FORMCHECKBOX  Noc. Mortgage services$ FORMTEXT       FORMCHECKBOX  Yes  FORMCHECKBOX  Nod. Credit card services$ FORMTEXT       FORMCHECKBOX  Yes  FORMCHECKBOX  Noe. Actuarial services$ FORMTEXT       FORMCHECKBOX  Yes  FORMCHECKBOX  Nof. Appraisal services$ FORMTEXT       FORMCHECKBOX  Yes  FORMCHECKBOX  Nog. Investment advisor/consultant/financial planner$ FORMTEXT       FORMCHECKBOX  Yes  FORMCHECKBOX  Noh. Real estate agents/agency$ FORMTEXT       FORMCHECKBOX  Yes  FORMCHECKBOX  Noi. Insurance agents/agency$ FORMTEXT       FORMCHECKBOX  Yes  FORMCHECKBOX  Noj. Data processing service$ FORMTEXT       FORMCHECKBOX  Yes  FORMCHECKBOX  Nok. Trust or other Asset Management services$ FORMTEXT       FORMCHECKBOX  Yes  FORMCHECKBOX  Nol. Securitization services$ FORMTEXT       FORMCHECKBOX  Yes  FORMCHECKBOX  Nom. Investment Banking services$ FORMTEXT       FORMCHECKBOX  Yes  FORMCHECKBOX  Non. Custodian Bank services$ FORMTEXT       FORMCHECKBOX  Yes  FORMCHECKBOX  Noo. Securities Lending services$ FORMTEXT       FORMCHECKBOX  Yes  FORMCHECKBOX  Nop. Tax planner/preparer$ FORMTEXT       FORMCHECKBOX  Yes  FORMCHECKBOX  Noq. Mutual fund/annuities$ FORMTEXT       FORMCHECKBOX  Yes  FORMCHECKBOX  Nor. Other (specify) FORMTEXT      $ FORMTEXT       FORMCHECKBOX  Yes  FORMCHECKBOX  No4. Has any applicant decreased or suspended dividends on any class of stock in the last 3 years, or, if this is a renewal of the policy, since the date of the last application or proposal form? FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf yes, provide details by attachment.5. Is any applicant considering or has any applicant been involved within the last 3 years, or, if this is a renewal of the policy, since the date of the last application or proposal form, in any actual or proposed merger, acquisition, divestment or sale of its stock in excess of 10% of the total stock outstanding? FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf yes, provide details by attachment.6. Has a private or public offering or a placement of securities been registered within the last 12 months or is such an offering or placement being considered for the next 12 months? FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf yes, provide details by attachment.7. Is there any material litigation threatened or pending against any applicant or any person in his or her capacity as a director, officer, employee or spouse or domestic partner of a director or officer of any applicant? FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf yes, provide details by attachment.8. Has any applicant been a party to any of the following:a. Any representative actions, class actions or derivative suits? FORMCHECKBOX  Yes  FORMCHECKBOX  Nob. Any civil, criminal or administrative proceeding alleging or investigating a violation of any security law or regulation? FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf yes, provide details by attachment.9. Does the Company or any subsidiary make any representations to consumers, customers or investors regarding any such entitys or its products "green" status, the management of its carbon footprint or that it otherwise runs its operations in an environmentally conscious manner? If yes, attach details.10. Has the Company or any subsidiary filed within the last 12 months, or any of them in the process of filing, any corporate climate change related or environmental disclosures (other than in connection with the Securities and Exchange Commission), including, but not limited to, submissions made to the Carbon Disclosure Project (CDP), FTSE 4 Good, CERES or ABI ClimateWise? If yes, attach details including the entities or programs to which submissions were provided.Answer the following three (3) questions if this is a request for a new policy, or, if any optional coverages have been requested for the first time on a renewal policy, answer the following with respect to those optional coverages in Section C.11. During the last 3 years:a. has any claim been made under any policy or has notice been given to any insurer? FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf yes, has the discovery or extended reporting period option been exercised for the cancelled or nonrenewed coverage? FORMCHECKBOX  Yes  FORMCHECKBOX  Nob. has any insurer refused, cancelled or nonrenewed coverage? (not applicable in Missouri) FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf yes, provide details by attachment.12. Does any applicant as defined in A 1 above or the employees of the applicant, have knowledge of any fact, circumstance or situation which they have reason to suppose might afford grounds for any claim such as would fall within the scope of the proposed insurance (including optional coverages for which a quote is desired)? FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf yes, provide details by attachment.13. Have any claims been made against any applicant as defined in A 1 above or any persons(s) in their capacity as an employee of the applicant or a spouse or domestic partner of the applicant such as would fall within the scope of the proposed policy (including optional coverages for which a quote is desired)? FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf yes, provide details by attachment. 14. Has the board of directors for the Company or any subsidiary established written policies and procedures addressing the following areas and are the policies reviewed regularly?Policy in WritingRegularly ReviewedFrequency of Review (e.g. annually, every 18 months, etc.)Information Security FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMTEXT      Internet and Computer Security FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMTEXT      Disaster Recovery FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMTEXT      Privacy FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMTEXT      Asset Liability Management FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMTEXT      Audits FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMTEXT      Loans FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMTEXT      C. Financial Institutions Select Coverage ScheduleSelect the coverage and complete the information requested or leave blank if no coverage is desired. *Note: No Retention shall apply to non-indemnifiable Loss incurred by Insured Persons except as required by state law.1.Coverage Part/CoverageLimitRetention* FORMCHECKBOX  Management Liability$ FORMTEXT      $ FORMTEXT       FORMCHECKBOX  New or  FORMCHECKBOX  RenewalIncluding Retired Independent Directors Liability (Side-A) Coverage**Aggregate Limit for all Retired Independent Directors is 10% of the Management Liability LimitNone**The limit for Retired Independent Directors Liability (Side-A) Coverage for Management Liability will also apply to Securities Coverage, if that coverage option is selected. FORMCHECKBOX  Civil Money Penalties FORMCHECKBOX  New or  FORMCHECKBOX  Renewal If a quote is desired, provide a list of those directors and officers that desire coverage by attachment.Limit: FORMCHECKBOX  $100,000 FORMCHECKBOX  $250,000 FORMCHECKBOX  $500,000 FORMCHECKBOX  $1,000,0002. FORMCHECKBOX  Non-Indemnifiable Excess DIC Liability$ FORMTEXT      None FORMCHECKBOX  New or  FORMCHECKBOX  Renewal3. FORMCHECKBOX  Private Company Securities  FORMCHECKBOX  Public Company Securities$ FORMTEXT      $ FORMTEXT       FORMCHECKBOX  New or  FORMCHECKBOX  Renewal FORMCHECKBOX  Derivative Demand Investigation Expenses$100,000 if coverage is selectedNone FORMCHECKBOX  New or  FORMCHECKBOX  Renewal4. FORMCHECKBOX  Employment Practices Liability$ FORMTEXT      $ FORMTEXT       FORMCHECKBOX  New or  FORMCHECKBOX  Renewal FORMCHECKBOX  Third Party Discrimination Liability$ FORMTEXT      $ FORMTEXT       FORMCHECKBOX  New or  FORMCHECKBOX  RenewalCoverage Part/CoverageLimitRetention*5. FORMCHECKBOX  Fiduciary Liability$ FORMTEXT      $ FORMTEXT       FORMCHECKBOX  New or  FORMCHECKBOX  Renewal Complete a separate Fiduciary Liability Insurance application if seeking this coverage.Voluntary Settlements and Defense Costs$100,000 sublimit if coverage is selectedNoneHIPAA Penalties$25,000 sublimit if coverage is selectedNone6. FORMCHECKBOX  Professional Liability$ FORMTEXT      $ FORMTEXT       FORMCHECKBOX  New or  FORMCHECKBOX  RenewalIncluding: FORMCHECKBOX  Broker Services Liabilitya. Current number of producing Registered Representatives FORMTEXT      b. Of the current number, how many are licensed as:Series 6 FORMTEXT      Series 22 FORMTEXT      Series 7 FORMTEXT      Series 24 or 27 FORMTEXT      Series 11 FORMTEXT      Other FORMTEXT      c. Are any proprietary products offered? If "yes", describe the products and the percentage of annual gross revenue they comprise, as an attachment. FORMCHECKBOX  Yes  FORMCHECKBOX  Nod. Is there an approved products list? FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf "yes", describe the procedure for selecting investments to be included on the approved products list, the procedures for updating that list and procedure for monitoring the performance of approved products, as a separate attachment. FORMCHECKBOX  Insurance Agent Services Liabilitya. Services offered include FORMCHECKBOX  Personal Lines FORMCHECKBOX  Commercial Lines FORMCHECKBOX  Life, Accident and Healthb. Total number of licensed agents FORMTEXT      c. Is current Insurance Agents Errors and Omissions coverage in effect? FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf "yes", identify the Company, policy period, limits of insurance and retention FORMTEXT       FORMCHECKBOX  IRA/Keogh Services LiabilityAre these accounts handled through the Trust Department?  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  No Trust DepartmentCoverage Part/CoverageLimitRetention*7. FORMCHECKBOX  Lender Liability$ FORMTEXT      $ FORMTEXT       FORMCHECKBOX  New or  FORMCHECKBOX  Renewal8. FORMCHECKBOX  Trust Department Liability$ FORMTEXT      $ FORMTEXT       FORMCHECKBOX  New or  FORMCHECKBOX  Renewal Complete a separate Trust Department Liability application if seeking this coverage.9.Security & Privacy Protection FORMCHECKBOX  New or  FORMCHECKBOX  Renewal Complete a separate Security and Privacy Protection application if seeking this coverage.Coverage Part/CoverageLimitRetention* FORMCHECKBOX  Security and Privacy Liability$ FORMTEXT      $ FORMTEXT       FORMCHECKBOX  Internet Media Liability$ FORMTEXT      $ FORMTEXT      Coverage Part/CoverageLimitRetention* FORMCHECKBOX  Privacy Breach Costs$ FORMTEXT      $ FORMTEXT       FORMCHECKBOX  Public Relations Expenses$ FORMTEXT      $ FORMTEXT       FORMCHECKBOX  Reward Payments$25,000, if coverage is selectedNone FORMCHECKBOX  Business Income Loss, Dependent Business Income Loss$ FORMTEXT      $ FORMTEXT       or  FORMTEXT       hours FORMCHECKBOX  Digital Asset Replacement Expense$ FORMTEXT      $ FORMTEXT       FORMCHECKBOX  Cyber Extortion Threat$ FORMTEXT      $ FORMTEXT      10.Additional Limit of Liability for Defense Costs: FORMCHECKBOX  $250,000 FORMCHECKBOX  $500.000 FORMCHECKBOX  $1,000,00011.Aggregate Limits of LiabilityIndicate below if one or both Aggregate Limits of Liability will apply and to which Liability Coverage Parts/Coverages. If applicable, each Coverage Part/Coverage can only be selected once. FORMCHECKBOX  Shared Aggregate Limit of Liability in each Policy Year$ FORMTEXT      under the following LiabilityCoverage Parts/Coverages FORMCHECKBOX  Management Liability FORMCHECKBOX  Professional Liability FORMCHECKBOX  Private/Public Company Securities Coverage (excluding Derivative Demand Investigation Expenses Coverage) FORMCHECKBOX  Lender Liability FORMCHECKBOX  Trust Department Liability FORMCHECKBOX  Employment Practices Liability FORMCHECKBOX  Security and Privacy Liability FORMCHECKBOX  Fiduciary Liability FORMCHECKBOX  Internet Media Liability FORMCHECKBOX  Shared Aggregate Limit of Liability in each Policy Year$ FORMTEXT      under the following LiabilityCoverage Parts/Coverages FORMCHECKBOX  Management Liability FORMCHECKBOX  Professional Liability FORMCHECKBOX  Private/Public Company Securities Coverage (excluding Derivative Demand Investigation Expenses Coverage) FORMCHECKBOX  Lender Liability FORMCHECKBOX  Trust Department Liability FORMCHECKBOX  Employment Practices Liability FORMCHECKBOX  Security and Privacy Liability FORMCHECKBOX  Fiduciary Liability FORMCHECKBOX  Internet Media Liability12.Combined Aggregate Limit of LiabilityIndicate below if a Combined Aggregate Limit of Liability will apply. FORMCHECKBOX  Combined Aggregate Limit of Liability in each Policy Year$ FORMTEXT      under all Liability CoverageParts/Coverages other than the Retired Independent Directors Coverage, Non-Indemnifiable Excess DIC Coverage, Derivative Demand Investigation Expenses, Privacy Breach Costs and the Additional Limit of Liability for Defense Costs. 13.DefenseIndicate below selections with respect to managing defense of claims. If "Insureds' duty to defend" is selected, then Insureds will choose defense counsel and it shall be the duty of the Insureds to defend any Claims. If "Insurer's duty to defend" is selected, then the Insurer will choose defense counsel regardless of whether the retention applicable to such Claim has or is likely to be exhausted, although the Insurer shall not be liable to pay covered Loss, including Defense Costs, with respect to such Claim until the applicable retention has been exhausted, and the Insurer shall have the right and duty to defend any Claim.A. Management Liability Coverage Part FORMCHECKBOX  Insureds Duty to Defend FORMCHECKBOX  Insurers Duty to DefendB. Non-Indemnifiable Excess DIC Liability Coverage Part FORMCHECKBOX  Insureds Duty to Defend FORMCHECKBOX  Insurers Duty to Defend FORMCHECKBOX  Not PurchasedC. All Other Liability Coverage Parts FORMCHECKBOX  Insureds Duty to Defend FORMCHECKBOX  Insurers Duty to Defend FORMCHECKBOX  Not PurchasedD. For the Financial Institution Select Bond, complete the following:1.a. Total full-time salaried officers, employees, retained attorneys and persons provided by employment contractors# FORMTEXT      b. Total part-time salaried officers, employees, retained attorneys and persons provided by employment contractors# FORMTEXT      c. Total banking locations (other than the Home Office of the first-named Insured) in the U.S., Canada, Puerto Rico and U.S. Virgin Islands# FORMTEXT      d. Total limited bank facilities in the U.S., Canada, Puerto Rico and U.S. Virgin Islands# FORMTEXT      e. Total nonbanking locations in the U.S., Canada, Puerto Rico and U.S. Virgin Islands# FORMTEXT      f. List the banking locations, limited banking facilities and nonbanking locations outside of the U.S., Canada, Puerto Rico and U.S. Virgin Islands: FORMTEXT       FORMTEXT      2.Does the applicant have any knowledge of acts, omissions, facts, circumstances or situations which might give rise to or afford grounds for any claim or loss that would be covered by the proposed bond (including optional coverages for which a quote is desired)? FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf yes, provide full details by attachment.3.Have any of your officers or employees committed a dishonest or fraudulent act at any time, whether in your employment or otherwise and whether or not such act was of the type covered by a financial institution bond? FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf yes, provide name of employee(s). FORMTEXT      4.Are annual vacations of at least one continuous week required for all officers and employees? FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf no, provide full details by attachment.5.Are procedures in place to preclude a transaction being fully controlled from origination to posting by one person?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf no, provide full details by attachment. 6.Is there a complete, annual audit by an independent CPA made in accordance with generally accepted auditing standards and so certified?If no, please provide full details. FORMTEXT       FORMTEXT      7.Is there a continuous internal audit by an internal audit department with the reports rendered directly to the board of directors?If no, please provide full details. FORMTEXT       FORMTEXT      8.Do any of the applicants in A 1 above or the applicants' employees routinely travel outside the United States or Canada? FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf yes, list country(ies) visited. FORMTEXT       FORMTEXT      9.Have there been any bond losses in the past 3 years? 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Jd$<<$7$8$H$Ifa$gd< Jd$<<$7$8$H$Ifgd<¡,.0M5 )d$$If]^gd<|kd^;$$Ifl0K*8) t044 laytHC$ Jd$<<$7$8$H$Ifa$gd< hd$<<$7$8$H$Ifgd<ovide an attachment.)Date of LossType of LossAmount of LossAmount Recovered from InsuranceAmount Recovered from other than InsuranceAmount of Loss PendingLocation at which Loss Occurred FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Copy of current declarations attached with changes noted FORMCHECKBOX  Amount of coverage and deductible desired indicated below (or leave blank if no coverage is desired)Insuring Agreement and Coverage OptionsLimit of LiabilityDeductible1.Basic  Fidelity (including Trading), On Premises, In Transit/Cash Letter, Counterfeit Currency$ FORMTEXT      $ FORMTEXT      Is coverage desired on businesses engaged in the data processing of the applicants' checks and accounting records related to such checks? FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf yes, provide the name and location of each processor.Name of ProcessorLocation FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      2.Unauthorized Signature or Alteration$ FORMTEXT      same as Basic 3.Securities$ FORMTEXT      same as Basic FORMCHECKBOX  with Loan Participation FORMCHECKBOX  without Loan Participation4.Audit and Claims Expense$ FORMTEXT      same as Basic5.Automated Teller Machines (ATM)$ FORMTEXT      $ FORMTEXT      If ATM coverage is desired, provide total number of ATMs FORMTEXT      6.Fraudulent Mortgages$ FORMTEXT      same as Basic7.Servicing Contractors$ FORMTEXT      same as BasicIf servicing contractor coverage is desired, provide total number of servicers FORMTEXT      8.Check Kiting Fraud$ FORMTEXT      same as Basic9.Computer Systems Fraud$ FORMTEXT      $ FORMTEXT      If computer systems coverage is desired, complete the following:a. For the computer system(s) the applicants operate, whether owned or leased.(1) Number of independent software contractors authorized to design, implement or service programs for theapplicants' System(s) FORMTEXT      (2) Number of ATMs FORMTEXT      (3) Is access to the applicants' system(s) by customers or other outside parties permitted by any way other than ATMs (e.g. by computer, terminal or touch-tone telephone keypad, etc.)? FORMCHECKBOX  Yes  FORMCHECKBOX  Nob. Other computer systems(1) Is coverage desired forAutomated Clearing Houses using Federal Reserve computer facilities FORMCHECKBOX  Yes  FORMCHECKBOX  NoFed Wire FORMCHECKBOX  Yes  FORMCHECKBOX  NoCHIPS FORMCHECKBOX  Yes  FORMCHECKBOX  NoSWIFT FORMCHECKBOX  Yes  FORMCHECKBOX  No(2) List any other computer system(s) for which coverage is desired (other than ATMs)Computer Systems FORMTEXT      (3) List any shared or other participatory ATMs for which coverage is desiredATM system(s) FORMTEXT      c. Is tested telex or other similar means of tested communication used? FORMCHECKBOX  Yes  FORMCHECKBOX  NoLimit of LiabilityDeductible10.Data Processing Service Operations$ FORMTEXT      $ FORMTEXT      11.Voice Initiated Transfer Fraud$ FORMTEXT      same as BasicVerification Callback Amount$ FORMTEXT      12.Telefacsimile Transfer Fraud$ FORMTEXT      same as BasicVerification Callback Amount$ FORMTEXT      13.a. Destruction of Data or Programs by Hacker$ FORMTEXT      $ FORMTEXT      b. Destruction of Data or Programs by Virus$ FORMTEXT      $ FORMTEXT      c. Is coverage desired for restoration of damaged or destroyed computer programs if such programs cannot be duplicated from other computer programs? FORMCHECKBOX  Yes  FORMCHECKBOX  No14.Voice Computer System Fraud$ FORMTEXT      $ FORMTEXT      15.Safe Deposit Boxa. Liability of Depository$ FORMTEXT      N/Ab. Loss of Customers Property$ FORMTEXT      N/AIncludes Money FORMCHECKBOX  Yes  FORMCHECKBOX  NoCombined Single Limit for a and b FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf safe deposit box coverage is desired, provide # of rented boxes  FORMTEXT       and # of locations with boxes  FORMTEXT      16.Stop Payment or Wrongful Dishonor$ FORMTEXT      $ FORMTEXT      17.Kidnap-Ransom-Extortion$ FORMTEXT      $ FORMTEXT      18.Debit Card$ FORMTEXT      $ FORMTEXT      19.Internet Banking wire Transfer Fraud$ FORMTEXT      $ FORMTEXT      For commercial banks only:20.Issuers of Register Checks or Personal Money Orders$ FORMTEXT      $ FORMTEXT      If issuers of register checks or personal money orders coverage is desired, provide the name and location of each issuerName of IssuerLocation FORMTEXT       FORMTEXT      For savings & loans, FSBs and savings banks only:21.Agents$ FORMTEXT      $ FORMTEXT      If coverage is desired on the applicants' appointed or elected agents (other than servicing contractors or data processors) performing any act or service in connection with the ordinary conduct on the business, provide the name and location of each agent.Name of AgentLocation FORMTEXT       FORMTEXT      E. Provide the following by attachment:  FORMCHECKBOX  Most recent annual report (or audited financial statements with all notes and schedules if no annual report is prepared)  FORMCHECKBOX  The letter (sometimes known as management letter) that accompanied latest audit that details recommendations and weaknesses, (material or otherwise), with respect to operations and internal control structure, along with written response to any comments made therein.  FORMCHECKBOX  Most recent Notice to Stockholders and Proxy Statement  FORMCHECKBOX  Most recent public filings or disclosures, including any 8k filings and proxy statements.  FORMCHECKBOX  List of names and major affiliations of all directors and names of all officers of the Company and subsidiaries.  FORMCHECKBOX  A full breakdown of the loan portfolio, if not provided by the documents above. This should include the percentage of commercial and industrial, commercial real estate, construction, and residential real estate loans in the portfolio. In addition, the breakdown should include total outstanding undrawn lines of credit (dollar amount). F. Disclosures With respect to the Financial Institutions Select Insurance Policy, read the following: WITHOUT PREJUDICE TO ANY OTHER RIGHTS AND REMEDIES OF THE INSURER, ANY CLAIM ARISING FROM ANY CLAIMS, FACTS, CIRCUMSTANCES OR SITUATIONS REQUIRED TO BE DISCLOSED IN THE RESPONSE TO QUESTIONS B. 12 and B. 13 ABOVE IS EXCLUDED FROM THE PROPOSED INSURANCE. The undersigned President or Chairman of the Board of Directors represents that to the best of his/her knowledge the statements set forth herein and any documents and information submitted in connection herewith are true, accurate and complete and that every effort has been made to obtain sufficient information from each and every entity and director and officer proposed for this insurance to facilitate the proper completion of this Application. The Insurer is hereby authorized to make any investigation and inquiry in connection with this Application. The undersigned further agrees that if the information supplied on or in connection with this Application changes between the date of this Application and the effective date of the insurance, the undersigned will immediately notify the Insurer and the Insurer may withdraw or modify any outstanding quotations or authorization or agreement to bind insurance. The signing of this Application does not bind the undersigned to purchase the insurance. However, it is agreed that this Application (and any previously executed proposal forms or applications) and any documents or information submitted herewith shall be the basis of the contract should a policy be issued and are to be considered as incorporated in and constituting part of the policy. Acceptance of this Application does not bind the Insurer to complete the insurance. IT IS ALSO AGREED THAT DISCLOSURE OF ANY INFORMATION ON THIS APPLICATION DOES NOT CONSTITUTE NOTICE AS REQUIRED IN GENERAL TERMS AND CONDITIONS SECTION VIII. REPORTING AND NOTICE, SHOULD A POLICY BE ISSUED. With respect to the Financial Institution Select Bond, read the following: The applicant represents that the information furnished in this application is complete, true and correct. This application constitutes part of the bond. Any intentional misrepresentation, omission, concealment or incorrect statement of a material fact, in this application or otherwise, shall be grounds for the rescission of any bond issued in reliance upon such information. The undersigned is an authorized representative of the applicant and certifies that reasonable investigation and inquiry has been made to obtain the answers to questions on this Application. When providing information for purposes of requesting a renewal, if applicable, the applicant has carefully reviewed the prior application form to ensure that the Insurer has been provided with updated information. The undersigned certifies that the answers are true, correct and complete to the best of his/her knowledge. G. FRAUD NOTICES: Prior to signing this application, review the following statutory fraud notices as they may apply to the applicant s domicile. Any person who knowingly and with intent to defraud any insurance company or another 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 the person to criminal and [NY: substantial] civil penalties. (Not applicable in CO, DC, DE, FL, HI, MA, NE, OH, OK, OR, VT or WA; in LA, ME, TN and VA, insurance benefits may also be denied). 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 policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement of award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. DISTRICT OF COLUMBIA: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits, if false information materially related to a claim was provided by the applicant. FLORIDA: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. HAWAII: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss of benefit is a crime punishable by fines or imprisonment, or both. MASSACHUSETTS, OREGON, NEBRASKA, VERMONT: Any person who knowingly and with intent to defraud any insurance company or another 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, may be committing a fraudulent insurance act, which may be a crime and may subject the person to criminal and civil penalties. OHIO: Any person who, with the intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deception statement is guilty of insurance fraud. OKLAHOMA: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. 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. H. Signatures By: FORMTEXT      Title: FORMTEXT      Date: FORMTEXT      Licensed Agent or Broker: FORMTEXT      License Number: FORMTEXT      COVERAGE CANNOT BE ISSUED UNLESS THIS APPLICATION FORM IS PROPERLY SIGNED AND DATED.     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