LIBERTY INTERNATIONAL UNDERWRITERS
(a division of Liberty Mutual Insurance Company,
hereinafter called “the Company”)
APPLICATION FOR INSURANCE
INDEPENDENT REVIEW COMMITTEE FOR INVESTMENT FUNDS
Notice: If issued, the policy will be on a claims made basis, and will be issued in reliance of the completeness and accuracy of the disclosures and statements in this application. The limits of liability and any deductible will apply to any defence costs payable under the policy.
I. / GENERAL INFORMATION1. / i. / Name of Insured (Independent Review Committee):
ii. / Mailing Address:
iii. / Date Established:
iv. / List of all current Independent Review Committee members:
1.) Chair:
2.)
3.)
4.)
5.)
2. / Requested Amount of Insurance:
i. Limits of Liability:
ii. Retention:
3. / Do current Independent Review Committee members also serve on other Independent Review Committees and/or Board of Directors? If ‘yes’, please describe below. / YesNo
4. / Can Independent Review Committee members secure outside advisors as deemed necessary in the execution of their mandate? If ‘no’, please explain below. / YesNo
5. / Do members of the Independent Review Committee routinely (at least semi-annually) attend Board meetings of the Investment Fund Manager? If ‘no’, please explain below. / YesNo
6. / Are all members of the Independent Review Committee considered independent (with no past or current relationship that could, in the opinion of a reasonable person, interfere with the member’s judgment regarding a conflict of interest)? If ‘no’, please explain below. / YesNo
7. / Does the Independent Review Committee conduct an annual review of both its effectiveness as a committee and the effectiveness of each of its members? If ‘no’, please explain below. / YesNo
8. / Does the Independent Review Committee perform any consulting services for the Investment Fund Manager? If ‘yes’, please detail below. / YesNo
9. / Is the mandate of the Independent Review Committee broader than the requirements outlined in National Instrument 81-107? If ‘yes’, please detail below. / YesNo
10. / i. In instances where the Independent Review Committee provides the Investment Fund Manager with standing instructions, how does the Independent Review Committee ensure compliance with any conditions imposed?
11. / ii. What steps are be taken by the Independent Review Committee in instances where it believes the Investment Fund Manager has not acted in compliance with relevant securities regulations?
II. / INVESTMENT FUND INFORMATION
1. / i. / Please fill out the chart below. For ‘Type’ please indicate if the fund is open/closed ended, etc.
Name of Each Fund and YearEstablished / AUM / Investment FundFamily Name
Name:
Established:
Type:
Brief Description: / Canada:
U.S.:
Other:
Total:
Name:
Established:
Type:
Brief Description: / Canada:
U.S.:
Other:
Total:
Name:
Established:
Type:
Brief Description: / Canada:
U.S.:
Other:
Total:
Name:
Established:
Type:
Brief Description: / Canada:
U.S.:
Other:
Total:
Name:
Established:
Type:
Brief Description: / Canada:
U.S.:
Other:
Total:
Name:
Established:
Type:
Brief Description: / Canada:
U.S.:
Other:
Total:
2. / Name of Investment Fund Manager:
3. / Place of Incorporation and Year Established:
4. / General Description of Operations:
5. / Is the Investment Fund Manager licensed to operate outside of Canada? If ‘yes’, please specify locations. / YesNo
6. / Has the Investment Fund Manager ever been found in violation of any securities regulation including, but not limited to National Instrument 81-102? If ‘yes’, please describe below. / YesNo
7. / Has the Investment Fund Manager provided the Independent Review Committee with copies of all relevant policies and procedures including those governing risk management and compliance? / YesNo
8. / Will the activities of the Investment Fund Manager include any of the following?
i. Interfund trading? / YesNo
ii. Transactions in securities of a related party? / YesNo
iii. Purchase of securities underwritten by a related party? / YesNo
iv. Plans to change the external auditor of the funds within the next 12 months? / YesNo
v. Plans to recognize or transfer any of the fund assets in the next 12 months? / YesNo
vi. Purchase of any Alternative Investment Products (Hedge Funds, Derivatives, etc.)? / YesNo
If ‘yes’ to any of the above in question 8, please detail below.
III. / OTHER INFORMATION
1. / i. / Name and Address of the law firm acting as counsel:
ii. / Does the law firm supply a written opinion as to the legality of any change in Investment and Management Policy?
2. / i. / Name and Address of the Firm employed as accountant:
ii. / State frequency and nature of auditing services conducted:
iii. / Is a complete physical check of money and securities made regularly? If ‘yes’, please indicate by whom. If ‘no’, please explain below. / YesNo
IV. / COVERAGE AND CLAIMS HISTORY
1. / Has any claim and/or suit been made against the Applicant, its predecessor, or any past or present director, partner, officer, or employee of the Investment Fund Manager?
Is the Applicant or any director, partner, officer or employee of the Investment Fund Manager thereof aware of or in possession of any knowledge of an act, error, omission or breach of duty committed in the rendering of professional services?
Has the Applicant or any members, employees, directors or predecessors of the Investment Fund Manager been the subject of disciplinary proceedings?
QUESTION IV.(1) REQUIRE RESPONSES REGARDING ANY CLAIM, SUIT OR INDICENT ANY APPLICANT IS AWARE OF OR HAS KNOWLEDGE OF, REGARDLESS OF WHETHER OR NOT THERE WAS ANY VALID AND/OR COLLECTIBLE INSURANCE APPLICABLE TO SUCH CLAIM, SUIT OR INCIDENT.
Further, if the response to any part of Question IV. (1) is yes, please provide:
- Name of Claimant/Potential Claimant
- Date of Act, Error, Omission or Personal Injury was committed or alleged to have been committed
- Date of Claim
- Nature of Claim
- Quantum
- Any legal opinion obtained as to liability
- Any legal, adjusting or indemnity payments to date
- Any legal, adjusting or indemnity reserves established
2. / Please detail any Directors and Officers and/or Professional Liability Insurance purchased by the Applicant for the past five years detailing the present insurance coverage first:
COMPANY / POLICY NO. /
POLICY PERIOD
/POLICY LIMIT
/DEDUCTIBLE
1.2.
3.
4.
5.
Please state date on which uninterrupted Directors and Officers and/or Professional Liability Insurance began:
V. / ADDITIONAL INFORMATION
Please attach copies of the following:
i. / Copy of most recently audited financial statements for each of the Investment Funds listed above;
ii. / Copy of most recent report filed by the Independent Review Committee as required by Sections 4.3 and 4.4 of National Instrument 81-107;
iii. / Copy of Independent Review Committee Charter (including indemnification and compensation agreements);
iv. / Brief biographies or CV’s related to each Independent Review Committee member;
v. / Copy of any additional contractual agreements pertaining to the Independent Review Committee and its relationship with the Investment Fund Manager;
VI. / ACKNOWLEDGEMENT
The undersigned authorized officer on behalf of the Applicant:
- Declares that the statements and disclosures in this application are complete and accurate;
- Declares that to the best of their knowledge, there are no known facts material to the risk to be insured that have not been disclosed in this application;
- Undertakes to provide the Company immediate notice of any material changes discovered between the date of this application and the effective date of the policy;
- Acknowledges that the Company, if it issues, the policy will be doing so in reliance of the completeness and accuracy of the statements and disclosures in this application;
- Acknowledges that if issued, this application will form part of the policy.
- 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.
Signed: / Signed:
Date: / Date:
Title: / Title:
(Must be Signed by the Chair of the Independent Review Committee) / (Must be Signed by the Investment Fund Manager)
Independent Review Committee Application (10/07)