ERISA Fidelity Application


48 Hour ERISA Fidelity Bond Application
(Do Not use for Probate/Fiduciary Bonds)
Please note, you are in a secure area

All information requested in this application must be complete for Applicant. Include FULL BUSINESS NAMES(S), FULL LEGAL NAMES, SOCIAL SECURITY NUMBERS, SPOUSES LEGAL NAMES, STREET ADDRESSES, ZIP CODES, AND PHONE NUMBERS.

Legal Name of Plan
Type of Business
Address
City/State/Zip
Phone
Fax
Email
Plan Administrator
Address     #        Street Name      St./Ave.
City/State/Zip
Social Security #
Phone
Fax
Email

Number of Trustees
Total Assets per Plan$
Note: The Pension Reform Act Requires a bond limit equal to 10% of the maximum assets that the insured thinks will be held in the plan over the next three years (per Federal Statute). The maximum bond limit required by Federal Statute is $500,000 (unless the isured is advised otherwise by the U S Department of Labor).
Bond Amount$
Effective Date
Is countersignature of checks drawn on the plan's funds required? Yes No
If not, by whom are checks signed?
If bond amount is in excess of $250,000, please answer the questions below:
Number of other employees assisting in handling the funds, if any
If this is not a new plan, who provided prior bond coverage?
Has there ever been any loss of the trust fund?
Explain:
Accounting Controls & Audits:
How frequently made?
By whom?
Are bank accounts reconciled by someone not authorized to deposit or withdraw therefrom?
Will Securities be subject to joint control Yes No
Describe safekeeping provisions:
If there is an Independent Administrator, does the plan's outside accountant review the handling of funds prior to their being transferred to the trust? Yes No

The present officers, employees, administrators and trustees of the insured, have to the best of the insured's knowledge and belief, while in the service of the insured always performed their respective duties honestly. There has never come to its notice or knowledge any information which in the judgement of the insured indicated that any of the said officers, employees, agents, partners or trustees are dishonest. Such knowledge that any official, officer or trustee signing for the insured may now have in respect to his or her own person acts or conduct, unknown to the insured, is not imputable to the insured.


By submitting information through this site, I authorize you and/or the surety to contact the individuals and companies given as references or other sources to gather information on the credit, character and capacity of the individuals and the company.
Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or application containing any false, incomplete, or misleading information is guilty of a felony per state statute.

Press the Submit button below or you can fax or email to:
fax (561) 997-7087 or email to: bonds@beacongroupinc.com. or call 1-800 545-9007 ext. 133
Richard S. Wurst, ARM, AAI - License D048332 (Office use only)




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