APPLICATION FOR REGISTERED INVESTMENT ADVISOR PROFESSIONAL LIABILITY INSURANCE (RISKS WITH ANNUAL REVENUES OF $200,000 OR LESS)

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NOTICE: THE POLICY FOR WHICH YOU ARE APPLYING IS WRITTEN ON A CLAIMS-MADE AND REPORTED BASIS. ONLY CLAIMS FIRST MADE AGAINST THE INSURED AND REPORTED TO THE COMPANY DURING THE POLICY PERIOD ARE COVERED SUBJECT TO THE POLICY PROVISIONS. THE LIMITS OF LIABILITY STATED IN THE POLICY ARE REDUCED, AND MAY BE EXHAUSTED, BY CLAIMS EXPENSES. CLAIMS EXPENSES ARE ALSO APPLIED AGAINST YOUR DEDUCTIBLE, IF APPLICABLE.
STEP A: DETERMINE PREMIUM based on desired Limits of Liability and Applicants Annual Revenues. Please contact Fox Point if Revenues exceed $200,000 and complete the Supplementary Application.
ANNUAL REVENUE BANDS with PREMIUMS listed below Limit of Liability * Deductible Under $75,000 $75,001 - $100,000 $100,001 - $150,000 $150,001 - $200,000 $ 500,000/$1,000,000 $5,000 $1,417 $1,667 $2,446 $3,427 $1,000,000/$1,000,000 $5,000 $1,539 $1,810 $2,656 $3,722 $1,000,000/$2,000,000 $5,000 $1,700 $2,000 $2,938 $4,113	*Other Liability and Deductible options are available.
STEP B: CALCULATE THE TOTAL AMOUNT to be remitted.
Total Premium from Step A: $0.00 + $200.00 Policy Fee (Required) = Total Remittance Amount: $200.00

1.	GENERAL INFORMATION
	Applicant Name:
	dba Name:
	Business Address:
	City:		State:	--Select One-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming	Zip:
	Phone:	() -	Fax:	() -
	Email:			Years in Business:
	Licenses Held:
	Professional Designations:
	Does the Applicant employ other Financial Advisors or utilize independent contractors to give investment advice on behalf of the Applicant?					Yes No

2.	FINANCIAL AND BUSINESS INFORMATION
	a.	Indicate fiscal year end date:   01 02 03 04 05 06 07 08 09 10 11 12 / 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
		Provide professional services by approximate percentage. Must equal 100%. Details of all services provided by the Applicant to be identified regardless of whether or not revenues are included in Question 2c.
		Professional Services	Percent	Professional Services	Percent
		Financial Plan Preparation/Advice	%	Product Sales Based On Financial Plan	%
		Discretionary Asset Management	%	Product Sales Not Based On Financial Plan	%
		Non-Discretionary Asset Management	%	Referral to Third Party Managers	%
		Divorce Financial Consulting	%	Third Party Pension Administration	%
		Tax Preparation	%	Asset Monitoring	%
		Accounting Services Other Than Tax Preparation	%	Other (please describe in detail)	%
	b.	As an advisor, does the Applicant recommend the use of alternative investments?			Yes No

	c.	Indicate below the total annual commissions and fee income derived from for all financial planning, investment advisory, and financial instrument sales/service activities for each of the following Fiscal Periods:
		Fiscal Year	Annual Revenues	% of Revenues Fee Based	If Current Year revenues exceed $200,000, complete the Supplementary Application
		Prior Year: 20	$	%
		Current Year: 20	$	%
		Projected Next Year: 20	$	%

	d.	Does the Applicant receive commissions?		Yes No
		If "Yes", provide a breakdown of total commission income by percent. Must equal 100%.
		Type of Product	Percent	Type of Product	Percent
		Mutual Funds	%	Life, Health, Disability, Accident, or Long Term Care	%
		Variable Annuities	%	REITs (including REIT Mutual funds)	%
		Listed Stocks	%	Viatical agreements, Senior settlements or Life Settlements	%
		Foreign Securities/ADRs	%	Unlisted Stocks, Unregistered Securities, Private Placements	%
		Investment Grade Bonds	%	Junk Bonds	%
		Hedge Funds/Funds of Funds	%	Options, Futures, Tangibles, CMO’s, Derivatives	%
		Other forms of Unregulated Securities (please describe)			%
	e.	What is the percentage of total revenue derived from the Applicant’s largest client?			%

3.	CLAIMS/LOSS HISTORY
	a.	Has the Applicant or any associated professional ever:
	1)	Had a professional license or registration denied, suspended, revoked, non-renewed, or restricted?	Yes No
	2)	Been formally reprimanded by any court, administrative or regulatory agency?	Yes No
	3)	Had a complaint filed with any consumer agency, state securities department, insurance department, or by the Applicant’s Broker-Dealer, DEC, NASD, or other regulatory agency?	Yes No
	4)	Been formally accused of violating any professional association’s code of ethics?	Yes No
	5)	Been convicted of a felony?	Yes No
	6)	Been involved in or is aware of any fee disputes involving suits?	Yes No
		If the answer to any question under 3a is "Yes", please explain
	b.	Has any Professional Liability claim(s), complaint or proceeding been made against the Applicant or any person or organization proposed for this insurance or any predecessor organization?	Yes No
	c.	Is (are) any person(s) or organization(s) proposed for this insurance aware of any fact, error, omission, circumstance, or situation that might provide grounds for any claim under the proposed insurance?	Yes No

4.	PRIOR INSURANCE
	a. Please provide the following information for any Errors & Omissions or Professional Liability Insurance the Applicant carried during the last three years:
	COMPANY	LIMIT OF LIABILITY	DEDUCTIBLE	PREMIUM	POLICY PERIOD FROM - TO	RETRO DATE
		$	$	$	-
		$	$	$	-
		$	$	$	-
	b. Has any Errors & Omissions or Professional Liability Insurance issued to the Applicant ever been declined, cancelled, or non-renewed?					Yes No
	If the answer is "Yes", please explain

PAYMENT OPTIONS
	A.	Check For Full Amount Due, Payable to Fox Point Programs, Inc.
	B.	Credit Card:	VISA  Mastercard  AMEX	Card Number:
				Expiration Date:	01 02 03 04 05 06 07 08 09 10 11 12 / 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024
	Applicant Statement & Agreement
			By checking this box, I attest that all information that I have provided on this application or any other document filled out in connection with it is true and correct.  I have withheld nothing that would, if disclosed, affect this application unfavorably.   Checking this box indicates my signature as agreement to these terms.