APPLICATION FOR PROFESSIONAL LIABILITY INSURANCE FOR INDEPENDENT LIFE REPRESENTATIVES AND FINANCIAL ADVISORS

NOTE: Completion of this application form does not bind the Insurer to offer the insurance nor does it obligate the Applicant to purchase the insurance. This application is a declaration and shall form part of any policy wich may be issued.



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NOTE: If the spaced provided to answer any of the questions on this application are insufficient to fully answer the question, please use the remarks section at the end of the form. If it is a continuation from a particular question, please be sure to indicate which question.

1. Name of the Applicant:

Address:

City:

Province:

Postal Code:

Email:

Phone Number:

Fax:

2. a) If you are incorporated, are you the sole shareholder and representative placing business through your firm? Yes No

b) If yes, do you want that name to appear as Named Insured: Yes No

If yes, full name of your corporation:

3. Do you sell mutal funds? Yes No

4. Do you sell segregated funds? Yes No

5. Name your principal insurance companies:

6. Establish your revenue as follows: (Gross income (commissions/bonuses/fees)): Life Insurance Mutual Funds Segregated Funds Financial Planning Bank Product Group Benefits, LTD and A.D.& D. Total

7. In the last three (3) years, have you been the subject of any professional liability claim(s) or have you filed a claim notice to an Insurer as a result of professional service? Yes No

If yes, provide the date of each claim, the circumstances, the amount involved and the current status. (Forward appendix to Monarch, if needed.)

8. Where do you hold a license(s): British Columbia Alberta Saskatchewan Manitoba Ontario Northwest Territories

9. Has your license been suspended in the last five (5) years? Yes No

If yes, provide detailed narrative statement. (Forward appendix to Monarch, if needed.)

10. Have you held a professional liability insurance policy in the past five (5) years? Yes No

If no, please advise why. If yes, please complete the following: Insurer Policy Number Policy Period

11. Date UNINTERUPTED E&O Insurance FIRST began:

12 a) Have you had an indication from a client to the effect that they may sue you, your employee(s) or a trainee? Yes* No

b) Does a request for documents from one of your clients lead you to believe that they may sue you, your employee(s) or a trainee? Yes* No

c) Do you have knowledge of any facts, that have been revealed or will have to be revealed to one of your clients that may result in a suit against you, your employee(s) or a trainee? Yes* No

d) Do you have knowledge of any facts, that if they were revealed to your clients, could result in a suit against you, your employee(s) or a trainee? Yes* No *If yes, please provide details to Monarch.

13. LIFE UNDERWRITERS with/without SEGREGATED FUNDS and WITHOUT MUTUAL FUNDS Amounts of Insurance $1,000,000. per claim / $2,000,000. annual Deductible: N/A $2,000,000. per claim / $4,000,000. annual Deductible: N/A MANITOBA ONLY: Amounts of Insurance $1,000,000. per claim / $5,000,000. annual Deductible: $1,000 $2,000,000. per claim / $5,000,000. annual Deductible: $1,000 LIFE UNDERWRITERS with/without WITH SEGREGATED FUNDS and WITHOUT MUTUAL FUNDS Amounts of Insurance $1,000,000. per claim / $2,000,000. annual Deductible: $1,000 $2,000,000. per claim / $4,000,000. annual Deductible: $1,000 MANITOBA ONLY: Amounts of Insurance $1,000,000. per claim / $5,000,000. annual Deductible: $1,000 $2,000,000. per claim / $5,000,000. annual Deductible: $1,000

Required effective date for this insurance:

REMARKS (optional - or use to complete questions above)