Get Western Surety Company 2018-2024

Agency Address Street City Agent s Code Form F6540-2-2011 State Zip Signature of Officer or Employer Official Title CNA is a registered service mark trade name and domain name of CNA Financial Corporation. No part of this material including the CNA Surety logo may be reproduced without written permission from CNA Surety Corporation.. APPLICATION FOR PENSION TRUST ERISA NAME SCHEDULE BOND Non-Union Plans Only Qualifying Assets Only Requested Bond Amount Effective Date Amount applies to each fiduciary listed below Is this bond required because more than 5 of the Plan assets are non-qualifying Yes No If yes please contact our office. Any questions on what constitutes a qualifying and non-qualifying asset should be addressed with your attorney or CPA. Legal Name of Plan s Type of Business Business Address Mailing Address Total Plan Assets Number of Participants Number of Trustees Each fiduciary trustee to be named please print Name Is the Plan audited by a CPA If no why is the plan not audited Previous ERISA coverage Date of last audit If yes list bond carrier Has applicant experienced any claims in the past five years If yes give specific details on each incident and any changes made to prevent a reoccurrence on a separate sheet. Premium payments for this new bond 1 year bond COMPLETE THE FOLLOWING FOR REQUESTS OF 500 000 AND LARGER What of Plan assets are employer securities Are Plan accounts reconciled by someone not authorized to deposit or withdraw funds Are two 2 or more signatures required for withdrawals and larger checks Are separate corporate trust account s established for the Plan assets If yes where are the assets held The undersigned agrees the above representations are an accurate statement of current information and procedures. This application with Bond Declarations and Provisions and endorsements issued to form a part thereof constitute the entire contract. APPLICATION FOR PENSION TRUST ERISA NAME SCHEDULE BOND Non-Union Plans Only Qualifying Assets Only Requested Bond Amount Effective Date Amount applies to each fiduciary listed below Is this bond required because more than 5 of the Plan assets are non-qualifying Yes No If yes please contact our office. Any questions on what constitutes a qualifying and non-qualifying asset should be addressed with your attorney or CPA. Any questions on what constitutes a qualifying and non-qualifying asset should be addressed with your attorney or CPA. Legal Name of Plan s Type of Business Business Address Mailing Address Total Plan Assets Number of Participants Number of Trustees Each fiduciary trustee to be named please print Name Is the Plan audited by a CPA If no why is the plan not audited Previous ERISA coverage Date of last audit If yes list bond carrier Has applicant experienced any claims in the past five years If yes give specific details on each incident and any changes made to prevent a reoccurrence on a separate sheet. Legal Name of Plan s Type of Business Business Address Mailing Address Total Plan Assets Number of Participants Number of Trustees Each fiduciary trustee to be named please print Name Is the Plan audited by a CPA If no why is the plan not audited Previous ERISA coverage Date of last audit If yes list bond carrier Has applicant experienced any claims in the past five years If yes give specific details on each incident and any changes made to prevent a reoccurrence on a separate sheet. Premium payments for this new bond 1 year bond COMPLETE THE FOLLOWING FOR REQUESTS OF 500 000 AND LARGER What of Plan assets are employer securities Are Plan accounts reconciled by someone not authorized to deposit or withdraw funds Are two 2 or more signatures required for withdrawals and larger checks Are separate corporate trust account s established for the Plan assets If yes where are the assets held The undersigned agrees the above representations are an accurate statement of current information and procedures.