| Name of Funds |
|
| Address |
|
| City |
|
| State |
|
| Zip |
|
| Contact Person |
|
| Phone |
|
| During the last five years: |
|
| Has the name of the Fund changed? |
|
| Has any other Fund amalgamated with or been merged into this
Trust Fund? |
|
| Explain |
|
| Current Carrier |
|
| Limit of Policy |
|
| Period (to & from) |
|
| Current Premium |
|
| Prior Carrier |
|
| Limit of Policy |
|
| Period (to & from) |
|
| Premium |
|
| Expiration Date |
|
| Total Participants by Fund |
|
| Total Contributions by Fund |
|
| Total Fund Assets |
|
| Total Number Trustees |
|
| Total Number Trust Fund & Plan Employees |
|
| Percent of Funds That are Self-Managed |
|
| At the present time, does the Fund have any real estate or
mortgage investments? |
|
| Have there been any changes in Fund providers (Enrolled
Actuary, Bankers, Independent Investment Manager, Professional Administrator,
Independent Qualified Public Accountants, Legal Counsel) over the last 5
years? |
|
| If above is Yes, Explain |
|
| Have any claims been made during the past 5 years against the
Fund or any of the present Trustees, or, to their knowledge, against any past
Trustees or errors & omissions? (except claims for benefits) |
|
| If above is Yes, Give details |
|
| Is the Fund or any Trustee aware of any circumstances which
may result in a claim against the Fund or any of the present or past Trustees
for errors or omissions? |
|
| If above is Yes, Give details |
|
| Policy Limit Requested |
|
| Deductible Requested |
|
Describe any area of concern
with regards to this coverage |
|
| May we use this form as a Broker of Record Letter? |
|
|
|
