Application For ERISA Bond

Agent
Name of Plan(s) to be covered
Address
Street Address City State ZIP Code
Effective Date of Bond
Number of Trustees
Total Plan Assets $
Total Non-Qualifying Assets $
(If more than 5% of total assets are “non-qualifying”, Inflation Guard Coverage is not offered. Submit to Company with Form 5500, Schedule I)
Amount of Bond $
Please enter a number less than or equal to 500000.
Bond amount is more than $250,000, please attach attach Form 5500, Schedule I)
Max. file size: 256 MB.
Have you sustained any employee dishonesty losses in the last six (6) years?
Is your Plan audited by a CPA?
Signature
Applicant Full Name
Email Address*
Agent / Broker
Phone
This field is for validation purposes and should be left unchanged.

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