(Please contact your attorney, CPA or plan administrator if you have questions, on
what
constitutes a qualified or non-qualified asset. If yes, please upload schedule of investments
below next to the yes option.)
Plan sponsor:
Plan Administrator
Insurance Fraud Warning
Any person who knowingly and with intent to defraud any insurance company or other person, files
an application for insurance, or a statement of claim containing any false information, or
conceals for the purpose of misleading information concerning any fact material thereto, commits
a fraudulent insurance act, which is a crime in certain Jurisdictions. The undersigned
applicant(s) hereby request(s) a bond and certify the truth of all statements in the
application, authorize any surety company(s) to verify this information at the time of
application and as needed, on an ongoing basis and to obtain additional information from any
source, including obtaining credit reports at the time of application, in any review or renewal,
at the time for any potential or actual claim, or for any other legitimate purposes as
determined by the company in it reasonable discretion.
