1. Agency Name. 2. Agency Code. the policy/bond.

How to complete an ERISA Compliance Bond Application
COMMERCIAL SURETY
1. Agency Name. List the agency name that will service
the policy/bond.
2. Agency Code. Indicate the Travelers agency code
under which the policy/bond will be issued.
3. Agency Contact. List the producer name and agency
contact (CSR) including telephone, fax and email.
Travelers issues policies through licensed and appointed agencies only.
ERISA Compliance Bond Application
Non-Union Welfare & Pension Plans
Agency Information
1
2
3
Producer Name: ______________________________________ Agency Contact: ______________________________________
Agency Name: _____________________________________________________________ Agency Code: __________________
4. Name of Plan Sponsor. Provide the complete
business name of the entity that serves as the
sponsor of the ERISA benefit plans to be insured.
Phone #: ______________________ Fax #: _______________________ Email: _______________________________________
5. Sponsor Address. Provide the complete physical
location mailing address.
__________________________________________________________________________________________________________
6. Policy Effective Date. Indicate the inception date of
coverage, which must be within 30 days of the date
you are completing the application.
7. Billing Method. Select either Agency Bill or Direct
Bill. If Direct Bill is chosen, a sponsor’s telephone
number is required.
8. Non-Qualifying Assets. Indicate if any of the plan
assets are designated as “non-qualifying” (e.g.,
jewelry, artwork, collectibles, mortgages, real estate).
9. Employer Securities. Indicate if any of the plan
assets contain employer securities (i.e., employee
stock plans issued by the employer).
10. Loss History. Indicate if any of the plans
currently have or ever had employee dishonesty
or fraud losses.
11. Bond Limit. List the total assets of each plan and
multiply by .10 to determine the bond limit per plan.
If there is more than one plan, .10 of the total assets
of each plan would be added together to reach the
total bond limit required. Note: Limits in excess of
$500,000 are available for plans that meet eligibility
requirements.
12. Coverage Limits and Premiums. Once the total
bond limit has been determined, reference the chart
for the corresponding three-year prepaid premium,
which includes Inflation Guard coverage. The total
premium for the three-year period is billed in full for
the first year. The renewal premium will include a 10
percent surcharge for Inflation Guard.
Sponsor Information
4
Name of Plan Sponsor (Business Name): _____________________________________________________________________
5
Sponsor Address (Street, City, State, Zip): _____________________________________________________________________
6
Policy Effective Date (within 30 days of today): _________________________________________________________________
7 □ Agency Bill
Billing Method:
or
□ Direct Bill
Sponsor Phone #: _____________________________________
(Required for Direct Bill)
8
1. Do any of the plans contain Non-Qualifying Assets?...........................................................................
Yes
(If yes, the insured is not eligible for coverage under this policy. Please contact your Bond Express underwriter.)
No
2. Do any of the plans contain Employer Securities?...............................................................................
(If yes, please forward details of the plan assets to your Bond Express underwriter.)
No
9
Yes
10
3. Have any of the plans incurred losses due to Fidelity claim(s)?.........................................................
Yes
No
(If yes,
forward
details
the loss to
your Bond Express
underwriter.)
Forplease
information
about
howofTravelers
compensates
independent
agents, brokers, or other insurance producers, please
visit this website:
Bond Limit
Complete
the worksheet below to determine your required limit.
http://www.travelers.com/w3c/legal/Producer_Compensation_Disclosure.html
Total Assets of Plan #1: __________________ x .10 = ___________________ Bond Limit Plan #1 (not to exceed $500,000) **
+ TotalIf Assets
of Plan
#2:can
__________________
x .10 = ___________________
Bond Or
Limit
Plan
#2write
(not to
$500,000) **
you prefer,
you
call the following toll-free
number: 1-866-904-8348.
you
can
toexceed
us at Travelers,
Enterprise
+ TotalDevelopment,
Assets of Plan One
#3: __________________
x .10 =CT
___________________
Bond Limit Plan #3 (not to exceed $500,000) **
Tower Square, Hartford,
06183.
= Limit Required: ______________________ should equal the sum of the Bond Limits above (Plan #1 + Plan #2 + Plan #3, etc.)
11
This application, including any material submitted in conjunction with the application or any renewal, does not amend the
Coverage
Limits or
& Premiums
Inflationpolicy
Guard)
provisions
coverages (Includes
of any insurance
or bond issued by Travelers. It is not a representation that coverage
*Please
noteor
that
for not
thisexist
added
a 10%
surcharge
be applied
to our
ERISA
bond premiums
renewal.on the facts and
does
does
forprotection,
any particular
claim
or losswill
under
any such
policy
or bond.
Coverage at
depends
circumstances
provisions, and any applicable3-Yr
law. Availability of
3-Yr involved in the claim or loss,
3-Yrall applicable policy or bond3-Yr
Bond coverage
Limit
Prepaid
Bond
Limit
Prepaid
Bond Limit qualifications
Prepaid
Bond regulations.
Limit
Prepaid
referenced in this
document
can
depend on underwriting
and state
12
Premium
Premium
Premium
Premium
$10,000
$111
$257 in the following
$190,000 states:$314
$325,000
$393
FRAUD STATEMENTS
–$100,000
Attention Insureds
$20,000
$110,000
$262 Mexico, and
$200,000
$319Any person $350,000
$408 willfully in D.C.
Arkansas,$114
D.C., Louisiana,
Maryland, New
Rhode Island:
who knowingly (and
$30,000
$137
$271 for payment
$210,000
$375,000 (and $425
and MD) presents
a false$120,000
or fraudulent claim
of a loss or $325
benefit or who knowingly
willfully in D.C. and
$40,000
$157 false information
$130,000in an application
$276
$220,000 is guilty
$331 of a crime $400,000
$436 to fines and
MD) presents
for insurance
and may be subject
$50,000
$180
$140,000
$282
$230,000
$336
$425,000
$450
confinement
in prison.
$60,000
$450,000
$467
Colorado:$197
It is unlawful $150,000
to knowingly $288
provide false, $240,000
incomplete, or$342
misleading facts
or information
to an insurance
$70,000
$217
$348
$475,000
$482
company for
the purpose $160,000
of defrauding or$294
attempting to $250,000
defraud the company.
Penalties
may include imprisonment,
fines,
$80,000
$231
$275,000
$496who knowingly
denial of insurance,
and $170,000
civil damages.$302
Any insurance
company or$365
agent of an $500,000**
insurance company
$90,000
$245 incomplete,
$180,000
$300,000
$379
provides false,
or misleading$308
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
*Note: The Travelers ERISA Compliance Bond automatically insures all ERISA Plans of the Sponsor. The Employee Retirement
be reported
to the
Colorado
Division
Insurance
the10%
Department
of handled
Regulatory
Incomeshall
Security
Act of 1974
(ERISA)
requires
a PlanofFidelity
Bond within
to equal
of the funds
by aAgencies.
Trustee/Fiduciary, with a
Florida:
Anyofperson
whoper
knowingly
andLimit
withofintent
to injure,
or deceive
any
insurer
a statement
of claim or
maximum
Bond Limit
$500,000
Plan**. The
Liability
for the defraud,
Bond should
equal the
sum
of thefiles
required
ERISA Bond
containing
false,
incomplete,
misleading
information
is guilty
of a
felony
of automatically
the third degree.
amountan
for application
each plan. The
Travelersany
ERISA
Compliance
Bond or
contains
a unique
Inflation Guard
feature.
This
feature
New per
Jersey,
and
AnySponsor/Plan
person whopurchases
knowinglyanand
with atintent
defraud
providesKentucky,
a bond amount,
Plan, New
equal York,
to that Ohio,
required
by Pennsylvania:
ERISA, provided the
amount
least to
equal
to any
the required
ERISAcompany
bond amount
at the person
Bond inception
These rates
are based on:
20% commission
rate,
5 or fewer any
Trustees,
and false
insurance
or other
files andate.
application
for insurance
or statement
of claim
containing
materially
no Fidelity
losses in the
3 years.
criteria
requires use
of the Travelers
ERISA any
Compliance
Bond Form.
Coverage
information
or past
conceals
forOur
theunderwriting
purpose of
misleading,
information
concerning
fact material
thereto
commits a
is available
for Non-Union
Plans
Non-Qualified
Assets,
Designated
Agents,
or Additional
Named Insured
coverage.
fraudulent
insurance
act,containing
which is no
a crime
and subjects
such
person to
criminal
and civil penalties.
(In New
York, Ifthe civil
applicant
does is
not
meet
these criteria,
please contact
Bondand
Express
underwriter.
penalty
not
to exceed
five thousand
dollars your
($5,000)
the stated
value of the claim for each such violation.)
13
**ERISAMaine,
may require
the limit to
exceed $500,000
if a plan holds
employer
securities,
multiple plansor
formisleading
one
Tennessee,
Virginia,
and Washington:
It non-qualifying
is a crime toassets,
knowingly
provide
false,or incomplete,
sponsor.
Limits above
are available
for these
sponsors,
butofrequire
prior Company
approval.
information
to$500,000
an insurance
company
for the
purpose
defrauding
the company.
Penalties include imprisonment, fines,
and denial of insurance benefits.
F-2727 (6/10)
© 2010 The Travelers Indemnity Company. All rights reserved.
Applicant Signature:
Producer Signature:
Page 1 of 2
Date:
14
State Producer License No. (required in FL)
Date:
Please complete and fax toll-free to: (866) 785-2463 or email to: BondExpressERISA@travelers.com
13. Inflation Guard. Automatically provides a limit of liability, adjusted at
the plan’s fiscal anniversary date, equal to the limit of liability required
by ERISA, provided the plan sponsor purchases the required limit of
liability at the policy’s inception. See coverage language for details.
F-2727 (6/10)
14. Signature/Date. An authorized representative (i.e., agent or
insured) must sign and date the application. Note: Producer
signature is required if the plan sponsor is located in New Hampshire
and the producer license number is required if the plan sponsor is
located in Florida.
© 2010 The Travelers Indemnity Company. All rights reserved.
Page 2 of 2
travelersbond.com
Travelers Casualty and Surety Company of America and its property casualty affiliates. One Tower Square, Hartford, CT 06183
This material does not amend, or otherwise affect, 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.
© 2013 The Travelers Indemnity Company. All rights reserved. Travelers and the Travelers Umbrella logo are registered trademarks of The Travelers Indemnity Company in the
U.S. and other countries. 56145 Rev. 9-13