FINANCIAL ADVISORS

Errors and Omissions Insurance Application

For representatives of:

First Name: / Initials: / Last Name:
Address: / City: / Province: / Postal Code:
Phone: / Work: / Home: / Fax: / Email:
Date Insurance is Required: (yy / mm / dd):
2. Indicate the area(s) in which you are licensed:
Mutual Funds
#Years Licensed / Life Sales***
#Years Licensed / Accident & Sickness
# Years Licensed / Securities
# Years Licensed
(*** Note: If Life Sales is selected Fraud coverage is included, if you are licensed in Alberta, Saskatchewan, Newfoundland and/or Ontario)
3. Indicate the province(s) in which you are licensed / registered?
Indicate the provinces that you are currently licensed for:
a)Life Insurance AB BC MB NB NS NF ON QC PEI SK YK NWT Nunavut
b)Accident & Sickness AB BC MB NB NS NF ON QC PEI SK YK NWT Nunavut
c)Mutual Funds AB BC MB NB NS NF ON QC PEI SK YK NWT Nunavut
d) Securities AB BC MB NB NS NF ON QC PEI SK YK NWT Nunavut
e) Other (describe)
4. IMPORTANT – PLEASE READ AND COMPLETE
a) Claims:
Have you (or any of your employees) ever been or currently the recipient of any claim in writing or verbally for actual or alleged errors, omission or negligent acts?
Yes No
If yes, please include details
b) Potential Claims:
Are you (or any of your employees) aware of any facts, circumstances or situations that may reasonably give rise to a claim, other than as advised above?
Yes No
If yes, please include details:
IT IS ACKNOWLEDGED AND AGREED THAT ANY LOSS ARISING FROM A MATTER DISCLOSED, OR WHICH SHOULD HAVE BEEN DISCLOSED IN 4 a) or b) ABOVE, IS EXCLUDED FROM COVER, ALL WITHOUT LIMITING ANY OTHER REMEDY AVAILABLE TO LIBERTY INTERNATIONAL UNDERWRITERS FOR NON-DISCLOSURE.
5.Please list all companies thatyou currently sell products for? (Please attach separate list if necessary) Do you have written contracts with these companies?
Company Contract Company Contract

1. Yes No 3. Yes No

2. Yes No 4. Yes No

6.What percentage of your portfolio is attributable to your sponsoring entity’s products based on?
Premium Dollars % Assets Under Management %
ii)What is the current volume of your client portfolio?Annual Premium: $ Number Of Clients:
Assets Under Management: Number Of Clients:
iii)What is the mix of your current portfolio:
a)i. life Insurance (%)
ii. accident & Sickness (%)
b)mutual funds (%)
c)Securities (%)
d) other (please describe)
What is your average size insurance account (by premium)? What is your average size investment account (by AUM)?
$ $

Additional Questions

Are you an owner - solely or partially - of a partnership or corporation through which you conduct business as a licensed representative?
If yes, please provide details including legal name, ownership structure, number and titles of employees, and purpose of the corporation /

Yes No

Has your license been revoked in the past 5 years?

If yes, why?
Have you been found guilty of any violation of Federal or Provincial Insurance or Securities Laws or Regulations?
If yes, please attach details.
Have you ever been audited by your sponsoring entity or any other company? If so, what were the results from that audit?
Yes No
i) Have you had any insurance company either decline to issue or cancel any errors and omissions insurance?
Yes No
Do you carry any other professional liability (E&O) coverage? Please provide detail i.e. Limit, Name of Insurance Company
i) What is the Limit on your expiring EO policy? $
Please select the Limit Option: (Input Selection)
DECLARATION
The Applicant for this insurance declares that, to the best of his/her knowledge and belief, the statements set forth herein are true and correct and that all reasonable efforts have been made to obtain sufficient information to facilitate the proper and accurate completion of this Application form. The Applicant further agrees that if any significant change in the condition of this Applicant is discovered between the date of this Application form and the date the insurance was purchased, which would render this Application form inaccurate or incomplete, notice of such change will be reported immediately in writing to the Liberty International Underwriters.
The undersigned acknowledges that any personal information provided in connection with the coverage applied for, including but not limited to the information contained in this application, has been collected in accordance with all applicable privacy legislation. The undersigned confirms that all necessary consents have been obtained for the collection, use, and disclosure of such information for the purposes of assessing the application for insurance, and if applicable, investigating and settling claims, detecting and preventing fraud, and acting as required or authorized by law.
Although submission of this Application form does not bind the Applicant to purchase the insurance, the Applicant agrees that this form and the information furnished pursuant thereto shall be the basis of the contract should a policy be issued and this form will become part of the policy.
For purposes of the Insurance Companies Act (Canada), this document was issued in the course of Liberty Mutual Insurance Company’s insurance business in Canada.
It is also agreed that should a policy be issued, eligibility for this insurance program is contingent upon membership in good standing as a representative of (NAME OF SPONSOR).
Date completed: (yy / mm / dd)
Signature of Applicant:

(12/09) Errors and Omission Insurance Coverage Application

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Liberty International Underwriters, a Division of the Liberty Mutual Insurance Company