Financial Planners Supplement

Financial Planners Professional Liability

FINANCIAL PLANNERS ADDENDUM TO APPLICATION
Name of Applicant:*
Prefix First Last Suffix
1. Investment Income

List the total gross receipts for the past twelve months derived from the sales of the following products and/or activities:
Fixed Annuities:*
Variable Annuities:*
Mutual Funds:*
Stocks:*
Bonds:*
Commodities:*
Financial Plans for a Fee:*
Total
$0.00
2. Do you have discretionary control of any client’s assets?*
- Yes
- No
If “Yes,” indicate the number of clients and the value of assets controlled:
Number of Clients:
Value of Assets Controlled:
3. Are you involved in the sale of structured settlement annuities?*
- Yes
- No
4. Do you have any involvement in the development or solicitation of general or limited partnerships?*
- Yes
- No
If “Yes,” provide full details:
THIS SUPPLEMENTAL APPLICATION IS ATTACHED TO AND FORMS PART OF THE PROFESSIONAL LIABILITY APPLICATION FOR CLAIMS-MADE INSURANCE. THIS SUPPLEMENT IS SUBJECT TO THE SAME PROVISIONS CONCERNING REPRESENTATIONS MADE IN THE GENERAL APPLICATION.
Signature:*
(Principal, Partner or Officer of the Firm)
Date:*
MM slash DD slash YYYY

Financial Planners Professional Liability