AN E&O PROGRAM FOR PROFESSIONALS ON THE …...- Built for Registered Investment Advisor firms (RIAs) or individual Financial Advisors (IARs), including options for insurance agents

AN E&O PROGRAM FOR PROFESSIONALS ON THE MOVE!

InterWeb's Financial Services E & O Program is designed for advisors regardless of how long you have been in the business or the breadth of your practice.

The Highlights

- Insured by National Casualty Company (an admitted carrier rated A+ Excellent: XV by AM Bests), part of the Nationwide

family of companies.

- Available in all states.

- Built for Registered Investment Advisor firms (RIAs) or individual Financial Advisors (IARs), including options for insurance agents

(life/health and property/casualty), sale of securities, financial planning and tax preparation.

- Limits up to $3 million per Wrongful Act / $3 million Annual Aggregate.

- Very competitive rates and retentions.

- Flexible eligibility guidelines.

- Covers “Traditional” and “Expanded” investments, including the use of ETFs, BDCs, options, REITs and other alternative

investments.*

- Includes coverage for certain fiduciary activities as defined under ERISA and DOL regulations.

Easy to Enroll in Minutes!

1. Apply as an Apply as an IAR or RIA firm.

2. Complete the Qualifying Questions (yes/no eligibility).

3. Review the Coverage Options Summary.

4. Complete the appropriate Rate Sheet, transfer costs to the Payment Form.

5. Pay by credit card, check or debit to checking. Monthly payments are available for your convenience.

We are here to help!

Contact InterWeb Insurance: 866 - 277 - 7162

Dee Cordea, Vice President, [email protected]

Kathy Phipps, Vice President, [email protected]

Sheri Pontolillo, Director, [email protected]

InterWeb Insurance’s Financial Services E & O Program is an affordable, “Instant Access” program designed to meet the needs of the majority of applicants. If you or your firm do not meet the eligibility requirements, are above the revenue thresholds or have broad-er coverage needs, please contact us. We can submit your application to the underwriter for special consideration so you can take advantage of the great benefits of the program.

* See the Coverage Option Summary for more details.

CONTACT INFORMATION FORM

Referred By: _______________________

INTRODUCTION

1. Determine if you are applying as an individual or as a firm. Rate Sheets 1 and 2 are for individuals; Rate Sheets 3a and3b are for an RIA Firm. RIAs with two or more advisors may see cost savings. In addition, as an RIA applicant, optionsare available to meet an IAR’s need for pre-hire prior acts and insurance agent or registered representativecoverage.

2. Complete the Qualifying Questions (yes/no eligibility questions and warranties – 2 pages). If you are not automaticallyeligible, please consider completing process (without payment) and we will submit your application for special underwriting consideration. We will call you to discuss your unique situation.

3. Review the Coverage Option Summary carefully for very important information regarding options andsupplemental coverage options for Transition Prior Acts and product sales as an IAR.

4. Complete the appropriate Rate Sheet and transfer the total costs to the Payment Form.

5. The Payment Form is where you will indicate your preferred payment method, exact amount due, down paymentand monthly payments (if desired).

6. Be sure to send all of the following signed and completed forms:

Contact Information Form

Payment Form

Rate Sheet 1, 2, 3a or 3b

Qualifying Questions (2 pages)

APPLICANT Show exactly as desired on Certificate of Insurance

Named Insured: _________________________________________ Company Name: _______________________________

Address: ______________________________________________________________________________________________

Office Phone: ________________________ CRD#: ________________________ Effective Date: ____________________

Contact Name: ____________________________________ Contact Email: _______________________________________

The Primary Contact: The individual noted above makes all representations, warranties and agreements on behalf of Applicant including its officers, directors, partners, employees and independent contractors for whom insurance is sought under this Application. All certificates of insurance will be emailed to the primary contact.

PRODUCT AND ACTIVITY Percentage Breakdown by Product

Applicant Signature: ____________________________________ Date: __________________________________________

Life / Health InsuranceFixed Life, Health,Disability % _________Fixed Annuity % _________Other Insurance % _________

Revenue: $ ________

SecuritiesVariable Products %_________

Stocks, Bonds % _________Mutual Funds % _________LP, REIT, PrivatePlacements % _________Other Securities % _________

Revenue: $ ________

Property & CasualtyPersonal Lines %________Commercial Lines % ________

Revenue: $ ________

AdvisoryVariable Products %_________

Stocks, Bonds % _________Mutual Funds % _________LP, REIT, PrivatePlacements % _________Other Securities % _________

Fee Revenue: $ ________

QUALIFYING QUESTIONS866-277-7162

INSTRUCTIONSApplicant must be able to truthfully answer “yes” to question 1 and “no” to questions 2 through 8 posed below in order to qualify for insurance coverage under this Program. Questions 2 or 3 may be answered yes, however a premium surcharge will apply. Call Customer Service. If Applicant fails to answer any question, or if Applicant answers “no” to question 1 or “yes” to any of the questions 2-8, Applicant will not qualify for coverage under this Program without additional underwriting review and approval. Applicant can be an Investment Advisory Firm (which would include all of its employees and its exclusive IARs as insureds) or an insurance agency and its employed and independent contractor named insured agents, acting as a “life insurance agent” and/or “property and casualty insurance agent” and/or Series 6 or 7 “registered representative” as set forth for that named insured on the Named Insureds Endorsement; provided, coverage for an employee or independent contractor of a named insured agency only applies with respect to covered activities carried out by, or through, or with the written approval of that named insured agency. The primary contact of the RIA or Agency entity makes all represen-tations, warranties and agreements on behalf of Applicant including its officers, directors, partners, employees and independent contractors for whom insurance is sought under this Application.

QUALIFYING QUESTIONS

Applicant Name: ______________________________________________

1. Does Applicant have a valid license/registration in all jurisdictions in which Applicant will act as an Agent, aRegistered Representative, a Registered Investment Advisor, and/or Investment Advisor Representative if applicable?

2. Has any complaint, claim, suit or arbitration for alleged malpractice, error, omission, mistake or other wrongfulacts been made against the applicant in the last 5 years? If yes, please complete 2a.

2a. If you answered yes to 2 are any of the following true: 1. Have you had more than one claim or incident as described above in the last 5 years?2. Are any claims still open?3. Did the paid indemnity on any claims exceed $10,000?

3. Has applicant been the subject of any investigation, inquiry or complaint by any state or federal regulatoryagency, consumer agency, or any other agency (including, but not limited to, the SEC, FINRA, and state securities,corporation or insurance department) that resulted in a regulatory enforcement or consent order, cease and desistorder or other enforcement order, disciplinary action, sanction, censure, reprimand, fine or suspension or in a formal reprimand by any court in the last 5 years, or is applicant currently under investigation by any of these authorities?IfYes, please complete 3a & 3b.

3a. If you answered yes to 3 are any of the following true:1. Have you had more than one incident as described above in the last 5 years?2. Are any of these incidents still open or unresolved?3. Did any of these incidents result in a fine or penalty in excess of $5,000 or in a suspension or being

barred from practice?

3b. Has Applicant been the subject of any investigation, inquiry or complaint by any state or federal regulatory agency, consumer agency, or any other agency (including, but not limited to, the SEC, FINRA, and state securities, corporation or insurance department) initiated and closed that resulted in a regulatory enforcement or consent order, cease and desist order or other enforcement order, disciplinary action, sanction, censure, reprimand, fine of $5,000 or less with no suspensions?

If you answered yes to 2 or 3 above, please contact InterWeb Insurance for further underwriting consideration.

4. After a review of Applicant’s records, does Applicant have any knowledge or information of any fact, situation,allegation or incident which may result in a complaint, claim, suit or arbitration against Applicant, including anyfee or other type of dispute with a client?

5. Has any professional license or registration of Applicant been denied, suspended, revoked, non-renewed orrestricted in any way in the last 10 years, or if Applicant is or was a Registered Representative, are there or werethere any “yes” answers on Applicant’s U-4 arising from issues in the last 10 years, or have any complaints beenexpunged in the last 10 years?

6. Has Applicant been convicted of any felony or of any business related misdemeanor, or is Applicant currentlyunder investigation or indictment or otherwise named as a defendant, respondent, or party to any criminalproceeding other than traffic violations, in the last 10 years?

7. Has any contract between Applicant and his/her insurance company, broker/dealer, registered investmentadvisor, or others been suspended, restricted, terminated or non-renewed for cause in the last 10 years?

8. Has Applicant had his/her professional liability insurance policy or fidelity bond declined, canceled, issued onspecial terms, renewal refused or had a request that his/her application for insurance or for a bond be withdrawnin the last 10 years?

YES NO

IndividualFirm

Page 1 of 2

QUALIFYING QUESTIONS

REPRESENTATIONS, WARRANTIES AND AGREEMENTS CONTINUEDApplicant makes the following representations, warranties and agreements:It is understood that the completion of this Application does not constitute acceptance of this Application or obligate the Company to complete the insurance applied for. It is understood and agreed that the language of the policy, and not any summary language or marketing material, will determine insurance coverage. ______ Initial

It is understood and agreed: (a) that this Application, including, without limitation, all information submitted verbally or in writing in connection herewith and not contained herein, will be relied upon by the Company in making a decision whether to issue coverage; (b) that this Application will be made a part of the policy; and (c) that any such coverage will be issued in reliance upon the representations made in connection with this Application. ______ Initial

It is understood and agreed that failure to provide a true and complete response to any of the questions, statements or requests for information in this Application or to provide any other information material to this Application will result in the voiding of the insurance coverage issued in reliance on this Application and denial of coverage for any claims asserted against Applicant. ______ Initial

Applicant authorizes and consents to investigation of information bearing upon Applicant's moral character, professional reputation, and qualifications to engage in the activities to be insured, including, without limitation, authorization to every person or entity, public or private, to release to the Company, its agents and authorized representatives, any documents, records or other information bearing upon the foregoing. It is understood and agreed that these investigations may not be confined to information submitted in this Application, but may include any other information deemed relevant by the Company. It is understood and agreed that organizations releasing such information, their agents, servants and employees shall not incur any liability as a result of any information released or furnished pursuant to this authorization, including any errors, omissions or mistakes contained in such released information. ______ Initial

Applicant must notify the Company within 10 days of any material change in the nature of Applicant’s business (including, without limitation, any changes in the answers to questions 1-8 above) while this Application is pending and throughout the term of any coverage issued by the Company. Failure to notify the Company will result in a denial of coverage under the policy terms and conditions. ______ Initial

NOTICE: Any person who knowingly and with intent to defraud an insurance company or its representatives files an application for insurance containing false information, or conceals information on any fact material thereto, commits a fraudulent insurance act which is a crime. ______ Initial

AUTO-RENEWAL INFORMATION- To streamline the renewal process for Applicants who become Insureds and who have no material changes during the policy period,the Auto-Renewal with Opt-Out Process will be utilized. You will be provided with the Auto-Renewal Notice email 90 days prior toexpiration and will be provided with the opportunity to opt-out of the Auto-Renewal. You will be provided with and reminded of thequalifying questions, the coverage options previously selected and the renewal costs.

- If you want to Auto-Renew, do nothing. Reminder: As soon as an insured knows of an alleged "wrongful act" which may result in acovered "written claim", the insured must give the insurer written notice of the details. All such notices are to be by a separate document and not part of the renewal application. See the policy for all claim reporting obligations and information. If you do not respond byopting out you will be warranting that you meet the qualifications and understand that coverage will be renewed and your credit cardor checking account via ACH will be charged.

- If you do not want to Auto-Renew, respond to the email by Opt-Out. A Customer Service Representative will contact you to confirmyour desire to not Auto-Renew and discuss further options. Please initial stating that you have read the above. ______ Initial

ACCEPTANCE1. I accept the representations, warranties and agreements.2. I understand that coverage applies only for the products and services listed in the coverage option I have selected.3. I understand the quoted rates only apply if accepted into this program.4. I understand that InterWeb Insurance collects an administrative fee which is nonrefundable in the event of cancellation. Please

reference fee disclosure at bottom of rate pages.5. I understand that Prior Acts coverage is available under the policy and applies only for products listed in the coverage option I have

selected and that not all options/features cover prior acts.6. By enrolling in the InterWeb Financial Services E & O Program, I hereby provide InterWeb Insurance with the credit card and bank draft

authorization and the right to automatically charge the renewal cost to the card or account in future years.7. By applying for this insurance, I am applying for membership in the Financial Services Professional Liability Purchasing Group Inc., a

group formed and operating pursuant to the Liability Risk Retention Act of 1986 (15 USC 3901et seq.).

Applicant Signature: ______________________________________________ Date: ___________________Page 2 of 2

COVERAGE OPTION SUMMARY

PRIMARY COVERAGE DESCRIPTIONS1A. Fixed Life Insurance – Provides coverage for the sale and servicing of life (including indexed products), accident and health (including Medicare advantage and supplemental insurance), long term care, disability insurance and other insurance that can be sold by a life insurance agent (other than annuities or property/casualty insurance). Coverage is limited to admitted carriers.1B. Fixed Life Insurance and Fixed Annuities - Provides coverage for the sale and servicing of life insurance and fixed annuities (including indexed products), accident and health (including Medicare Advantage and Supplemental insurance), long term care, disability and other insurance that can be sold by a life insurance agent (other than variable annuities or property/casualty insurance). Coverage is limited to admitted carriers.1C. Fixed & Variable Life Insurance, Annuities and Mutual Funds - Provides coverage for the sale and servicing of mutual funds, life insurance, fixed and variable annuities (including indexed products), accident and health (including Medicare Advantage and Supplemental insurance), long term care, disability insurance and other insurance that can be sold by a life insurance agent (other than property/casualty insurance). Coverage is limited to admitted carriers.1D. Personal Lines Property/Casualty Insurance - If the insured has 50% or more of his/her revenue from the sale of the products insured under coverage options 1A, 1B, or 1C, coverage 1D can be added for the stated additional charge to add coverage for the sale and servicing of personal lines property/casualty insurance (auto, recreational vehicle, watercraft, motorcycle, homeowners, renters, personal umbrellas, and pet insurance) per the Traditional Personal Property and Casualty Insurance Endorsement. Coverage is limited to admitted carriers.1E. Personal and Traditional Commercial Lines Property/Casualty Insurance - If the insured has 50% or more of his/her revenue from the sale of the products insured under coverage options 1A, 1B, or 1C, coverage 1E can be added for the stated additional charge to add coverage for the sale and servicing of personal (auto, recreational vehicle, watercraft, motorcycle, homeowners, renters, personal umbrellas, and pet insurance) and commercial lines property/casualty (workers compensation and employers liability, general and products liability, business owners and commercial multi-peril, auto (other than long haul trucking) and prop-erty) per the Traditional Personal and Commercial Lines Insurance Endorsement. Coverage is limited to admitted carriers.1F1. Series 7 Registered Representative with Traditional Investments - Provides coverage for the sale and servicing of life insur-ance, fixed and variable annuities (including indexed products), accident and health (including Medicare Advantage and Supplemental Insurance), long term care, disability insurance and other insurance that can be sold by a life insurance agent (other than property/casu-alty insurance), mutual funds and other securities otherwise covered by the policy. Coverage is limited to admitted carriers.1F2. Series 7 Registered Representative with Expanded Investments - Provides coverage for the sale and servicing of life insur-ance, fixed and variable annuities (including indexed products), accident and health (including Medicare advantage and supplemental insurance), long term care, disability insurance and other insurance that can be sold by a life insurance agent (other than property/ca-sualty insurance). Coverage is limited to admitted carriers. Coverage includes the sale of mutual funds, ETF's and ETN's, publicly traded stocks and bonds, registered but non-traded REITS, registered real estate and leasing limited partnerships and registered Business Devel-opment Companies, per the Diversification Endorsement, inverse securities per the Inverse Securities Endorsement, Covered Calls and Protective Puts, and other securities not otherwise excluded.1G. Tax Preparation - Provides coverage for preparation of personal and business tax returns per the Tax Preparation Endorsement.3H and 4H - Discretionary Financial Planning and Investment Management Services with Traditional Investments - Provides coverage for financial planning and investment management services including non-discretionary management, the use of subadvisors and discretionary management. Discretion is limited to the use of mutual funds, ETF's and ETN's, publicly traded stocks, bonds, and other securities not otherwise excluded. 3H is Individual IAR Option and 4H is RIA Firm Option.3I and 4I - Discretionary Financial Planning and Investment Management Services with Expanded Investments - Provides coverage for financial planning and investment management services including non-discretionary management, the use of subadvisors and discretionary management. Discretion is limited to the use of mutual funds, ETF's and ETN's, publicly traded stocks and bonds, registered but non-traded REITS, registered real estate and leasing limited partnerships and registered business development companies, per the Diversification Endorsement, inverse securities per the Inverse Securities Endorsement, and other securities not otherwise exclud-ed. 3I is Individual IAR Option and 4I is RIA Firm Option.

NOTE: Options 3H and 3I for Individual Investment Advisory Reps includes prior acts back to First Continuous E & O. The TPA Options are not necessary.

OPTIONAL COVERAGE DESCRIPTIONS - For Agency and RIA Firms OnlyTPA 4H and TPA 4I / Transition Prior Acts - For Investment Advisor Representatives joining a Registered Investment Advisor firm to purchase prior acts coverage for their activities prior to joining the firm; In the event of a claim, a condition of coverage is the proof of contin-uous E & O dating back to the earliest date of the covered professional service(s) giving rise to the claim(s). Without the TPA/Transition Prior Acts Option, the Primary Coverage Option will only apply to professional services performed on behalf of the enrolled Insured Entity. This additional coverage is for individuals covered under RIA Firm Options 4H and 4I. RIA-1A, RIA-1B and RIA-1C / Life Agent and Registered Representative for Specific Product Sales - Surcharge is per investment advisor representative who is dually licensed as a life insurance agent or registered representative to add coverage for the sale or servicing of life/health insurance, fixed indexed annuities, variable annuities and mutual funds. Refer to Primary Coverage Descriptions for products defined in coverage 1A, 1B and 1C.

This summary is provided for your convenience. It is an incomplete summary of the policy terms and conditions. This contains some, but not all, features that determine coverage. A copy of the specimen policy is available by contacting Kathy Phipps at [email protected].

This is the copyrighted work product of InterWeb Insurance ©2018 InterWeb Insurance

RATE SHEET 1INDIVIDUAL AGENTS & REGISTERED REPS

PLUS TAX PREPARATIONCOST AND OPTIONS

1A, 1B, 1C, 1D & 1E, 1F1 & 1F2, 1G

Revenues exceeding $500,000 - submit for individual price

*Limits $1M/$1M $1M/$2M $1M/$3M $2M/$2M $3M/$3MRetention $1,000 $1,000 $1,000 $1,000 $1,000

Base Cost $500 $520 $530 $850 $1,025


Base Cost $550 $585 $590 $1,000 $1,150

*Limits $1M/$1M $1M/$2M $1M/$3M $2M/$2M $3M/$3M

Retention1 $1,000 $1,000 $1,000 $1,000 $1,000Base Cost $650 $685 $690 $1,225 $1,400

1Mutual Funds and Variable Products Retention is $5,000

Individual Agents & RRs with Revenue up to $500,000

Personal Lines*Limits $1M/$1M

Retention $5,000Base Cost Surcharge $425

1F1*Limits $1M/$1M

Retention $5,000/$10,000

Base Cost $1,825

*Limits $1M/$1MRetention $5,000

Surcharge $675

Personal & Commercial Lines$1M/$1M

$5,000/$10,0002

$575

$5,000/$10,000/$50,0004

$3,125

3Expanded Investments defined in 1F2

4

2

1F2 (includes Expanded Investments)3

$1M/$1M

COVERAGE OPTION 1A = FIXED LIFE

COVERAGE OPTION 1B = OPTION 1A PLUS FIXED ANNUITIES

COVERAGE OPTION 1C = OPTION 1B PLUS MUTUAL FUNDS & VARIABLE

COVERAGE OPTIONS 1D & 1E = PROPERTY CASUALTY OPTIONS (Cannot be Purchased Alone)

COVERAGE OPTIONS 1F1 & 1F2 = SERIES 7 REGISTERED REPRESENTATIVE

COVERAGE OPTION 1G = TAX PREPARATION (Cannot be Purchased Alone)

Commercial Lines retention is $10,0002

$5,000 for Mutual Funds & Variable Products/$10,000 for other securities/$50,000 for Diversification Endorsement Investment Products4

All base costs include a fully-earned administration fee of $150 collected by InterWeb Insurance and a policy issuance fee of $25 or $50 collected by Prosurance Group depending upon the option(s) chosen. If the monthly payment option is chosen, each payment will include a $10 charge. If the policy is cancelled due to non-payment, and reinstatement is desired, a $50 reinstatement fee will apply in addition to any other amounts due. Coverage cancelled by the insured within the first 60 days is subject to minimum earned premium requirements.

*Limits mean Each “Wrongful Act” Aggregate / Named Insured Aggregate

I have reviewed the Coverage Option Summary prior to making my selection(s).

Applicant Signature: _________________________________________________ Date: _______________________

Applicant Name: ____________________________________________

Rate Sheet 1

Total: $________________Insert total of all selections

1

RATE SHEET 2INDIVIDUAL INVESTMENT ADVISOR REPS

COST AND OPTIONS 3H AND 3I

COVERAGE OPTION 3IDiscretionary Financial Planning and Investment Management Services w/Expanded Investments – Provides coverage for financial planning and investment management services including non-discretionary management, the use of subadvisors and discretionary management. Discretion is limited to the use of mutual funds, ETF’s and ETN’s, publicly traded stocks, bonds, registered but non-traded REITs, registered real estate and leasing limited partnerships and registered business development companies, per a Diversification Endorsement, inverse securities per an Inverse Securities Endorsement, and other securities not otherwise excluded.

COVERAGE OPTION 3HDiscretionary Financial Planning and Investment Management Services w/Traditional Investments – Provides coverage for financial planning and investment management services including non-discretionary management, the use of subadvisors and discretionary management. Discretion is limited to the use of mutual funds, ETF’s and ETN’s, publicly traded stocks, bonds, and other securities not otherwise excluded.

Coverage Option 3H or 3I + 1A (Fixed Life)

Coverage Option 3H or 3I + 1B (Option 1A + Fixed Annuities)

Coverage Option 3H or 3I + 1C (Option 1B + Mutual Funds & Variable)


Rate Sheet 2

Total: $______________

Insert total of all selections




Retention

Base Cost $875 $925 $975 $1,425 $2,175

ADDITIONAL COVERAGE OPTIONS AND RETENTIONS (Cannot Be Purchased Alone at These Reduced Costs)

Varies by AUMs - Chart Below


Retention

Base Cost $1,075 $1,125 $1,175 $1,925 $2,975

Varies by AUMs - Chart Below

RETENTIONS


AUMs

AUMsAUMs

$0-$25M

$25M-$100M$100M-$1B

$5,000

$10,000

$25,000

$5,000

$10,000

$25,000

$5,000

$10,000

$25,000

Diversification Endorsement Investment Products will have $50,000 retention


Surcharge $75 $90 $100 $300 $450


Retention $1,000 $1,000 $1,000 $1,000 $1,000

Surcharge $100 $115 $125 $375 $550


Retention3 $1,000 $1,000 $1,000 $1,000 $1,000Surcharge $125 $140 $150 $450 $675

Applicant Name: ____________________________________________

2

$10,000

$15,000

$25,000

$10,000

$15,000

$25,000

2

3Mutual Funds and Variable Products retention is $5,000

RATE SHEET 3aREGISTERED INVESTMENT ADVISOR FIRM

TWO OR MORE IARS COST AND OPTIONS

4H AND 4II

AUM

*Limits $1M/$1M $1M/$2M $1M/$3M $2M/$2M $3M/$3M $1M/$1M $1M/$2M $1M/$3M $2M/$2M $3M/$3M Retention $5,000 $5,000 $5,000 $10,000 $10,000 $10,000 $10,000 $10,000 $15,000 $15,000

Base Cost $1,450 $1,600 $1,750 $2,300 $2,900 $2,050 $2,200 $2,400 $3,100 $3,900

AUM


Base Cost $2,800 $3,050 $3,300 $4,150 $5,200 $3,850 $4,200 $4,650 $5,500 $7,000

AUM


Base Cost $5,350 $5,800 $6,450 $7,400 $9,500 $6,700 $7,200 $7,950 $9,400 $12,300

AUM *Limits $1M/$1M $1M/$2M $1M/$3M $2M/$2M $3M/$3M

Retention $25,000 $25,000 $25,000 $25,000 $25,000 Base Cost $7,950 $8,700 $9,700 $12,300 $16,400

$750,000,001- $1,000,000,000

$0 - $25,000,000

$50,000,001 - $100,000,000

$250,000,001 - $500,000,000

$100,000,001 - $250,000,000

$25,000,001 - $50,000,000

$500,000,001 - $750,000,000

COVERAGE OPTION 4HDiscretionary Financial Planning and Investment Management Services w/Traditional Investments – Provides coverage for financial planning and investment management services including non-discretionary management, the use of subadvisors and discretionary management. Discretion is limited to the use of mutual funds, ETF’s and ETN’s, publicly traded stocks, bonds, and other securities not otherwise excluded.

COST PER FIRM WITH TWO OR MORE PROFESSIONALS (including Independent Contractor IAR’s)AUM

*Limits $1M/$1M $1M/$2M $1M/$3M $2M/$2M $3M/$3M $1M/$1M $1M/$2M $1M/$3M $2M/$2M $3M/$3M

Retention $5,000 $5,000 $5,000 $10,000 $10,000 $10,000 $10,000 $10,000 $15,000 $15,000

Base Cost $1,100 $1,200 $1,300 $1,800 $2,300 $1,500 $1,625 $1,750 $2,500 $3,200

AUM

*Limits $1M/$1M $1M/$2M $1M/$3M $2M/$2M $3M/$3M $1M/$1M $1M/$2M $1M/$3M $2M/$2M $3M/$3M Retention $10,000 $10,000 $10,000 $15,000 $15,000 $25,000 $25,000 $25,000 $25,000 $25,000 Base Cost $2,050 $2,200 $2,350 $3,450 $4,400 $2,750 $3,000 $3,250 $4,700 $6,100

AUM


Base Cost $3,800 $4,150 $4,500 $6,500 $8,500 $4,700 $5,200 $5,700 $8,400 $11,200

AUM *Limits $1M/$1M $1M/$2M $1M/$3M $2M/$2M $3M/$3M

Retention $25,000 $25,000 $25,000 $25,000 $25,000 Base Cost $5,700 $6,250 $6,950 $11,200 $15,200

$750,000,001- $1,000,000,000

$0 - $25,000,000

$50,000,001 - $100,000,000

$250,000,001 - $500,000,000

$100,000,001 - $250,000,000

$25,000,001 - $50,000,000

$500,000,001 - $750,000,000

Applicant Name: ____________________________________________


Rate Sheet 3a

Total: $________________



COVERAGE OPTION 4IDiscretionary Financial Planning and Investment Management Services with Expanded Investments – Provides coverage for financialplanning and investment management services including non-discretionary management, the use of subadvisors and discretionarymanagement. Discretion is limited to the use of mutual funds, ETF’s and ETN’s, publicly traded stocks, bonds, registered but non-tradedREITs, registered real estate and leasing limited partnerships and registered business development companies, per a DiversificationEndorsement, inverse securities per an Inverse Securities Endorsement, and other securities not otherwise excluded.

RATE SHEET 3bREGISTERED INVESTMENT ADVISOR FIRM

TWO OR MORE IARSADDITIONAL COVERAGE OPTIONS

Transition Prior Acts Coverage – For investment advisor representatives joining a registered investment advisor firm to purchase prior acts coverage for their activities prior to joining the firm. Continuous E&O coverage is required.

Surcharge to Add Insurance, Annuities and Mutual Funds Coverage – Surcharge is per investment advisor representative who is dually licensed as a life insurance agent or registered representative. Refer to Primary Coverage Descriptions for products defined in coverages 1A, 1B, and 1C.

ADDITIONAL COVERAGE OPTIONS

Applicant Name: ____________________________________________


*Limits 1M/1MRevenue $0 - $500,000 500,000 - $1,000,000

Cost is per individualList persons below & indicate selections

Transition Prior Acts

Coverage TPA-4H $500Coverage TPA-4I $700

Surcharge to add “Life Plus”

Coverage RIA-1A (Fixed Life / Health) $50

Coverage RIA-1B (Option 1A plus Fixed Annuities) $75

Coverage RIA-1C (Option 1B plus Variable & Mutual Funds) $100

IndividuallyPriced

Transition Prior Acts for Advisors

Joining RIA

Surcharge to Add Sale of Insurance, Annuities and

Mutual Funds to RIA

TPA-4H $500

TPA-4I$700

RIA-1A $50

RIA-1B $75

RIA-1C$100

Insert the cost for each option being chosen for each person and carry over total.

CarryOver

Totalsand

CombineBelow

$

$

$

$

$

$

$

$

$

$

Rate Sheet 3b

Total: $________________

Names Below



PAYMENT FORM

Grand Total $

Pay in Full Insert Grand Total from above$______

MonthlyPayments

Pay 25% of the Total as Initial Payment . Remainin g 75% will be 9 equal payments beginning the month after the

effective Date. A per-installment fee of $10 also appli es.

Grand Total $______ x .25 = Initial Payment $______

PaymentDue Now

$______

SELECT ONE PAYMENT OPTIONS

or

Applicant Name: ____________________________________________ Desired Effective Date: ____/____/____

Coverage Options 1A, 1B, 1C, 1D, 1E, 1F1, 1F2 & 1G: Insurance, Securities, Tax Prep Rate Sheet 1 $__________

Coverage Options 3H & 3I: Individual Investment Advisor Reps, Rate Sheet 2 $__________

Additional Coverage Options 1A, 1B or 1C

Rate Sheet 3a $__________Coverage Options 4H & 4I: RIA Firm (2 or more IAR’s)

Coverage Options TPA 4H & 4I, RIA 1A, 1B & 1C: Additional RIA Firm Options Rate Sheet 3b $__________

Payment Options: Pay in full by credit card, or check, or monthly payments via credit card subject to down payment. Payments will be the responsibility of the Primary Contact. Failure to make the payment(s) will result in loss of coverage for all individuals

PAYMENT METHOD OR CREDIT CARD Pay in Full Monthly Payments Pay in Full CHECK Monthly Payments

Monthly Payments Initial Payment Amount: $ ____________ Monthly Payment Amount: $ ____________The down payment will be 25% of the Total Cost above. You may pay the down payment and 9 remaining monthly installments by ACH debit to checking or credit card. The monthly payments will begin the month following the inception of coverage and each will include a $10 installment fee. By signing below, you agree to this process and fees.

AUTHORIZATIONI, ___________________________, authorize InterWeb Insurance to charge my credit card or bank account as indicated above, from the credit card information listed above or the ACH authorization form enclosed. This payment authorization is valid and to remain in full force and effect unless I notify InterWeb Insurance of its cancellation by sending written notice to [email protected]. Please note: There is a minimum earned premium if insured cancels in first 60 days of inception. Broker administration fees are not refundable.

Cardholder Signature: ____________________________________ Print Name: _____________________________________

Applicant Signature: ____________________________________ Date: __________________________________________

via ACHQuestions? Call InterWeb at 866-277-7162

Where to send? Please make check payable to InterWeb Insurance

Mail 94 Acoma Blvd. S. Ste. 200 Lake Havasu City, AZ 86403 Email [email protected]

Fax 888-370-2843

Offered By InterWeb Insurance Brokers AZ License No. 1077048 1Must complete ACH Enrollment form and return with voided check.

1

For your privacy and protection, if you select credit card, your InterWeb Account Manager

will contact you by phone to process your payment upon receipt of these forms.

Remaining 75% of Grand Total is $_____ ÷ 9 = Monthly Amount of $_____ + $10 Installment Fee = $_____

Documents

AN E&O PROGRAM FOR PROFESSIONALS ON THE …...- Built for Registered Investment Advisor firms (RIAs) or individual Financial Advisors (IARs), including options for insurance agents