Certificates of Insurance Mary L. Stanford, CLU, ChFC STANFORD & CO.
President
Insurance Consultants
100 Second Ave. So.
Suite 200
St. Petersburg, FL 33701
(813) 822 -4880
FAX: (813) 822 -4679
March 14, 1989
Mrs. Donna Perez
Monroe County Administrative Services
Risk Management
Room 209 -Wing II
Public Service Building
Stock Island
Key West, Florida 33040
Dear Donna:
Per your telephone request, enclosed is another copy of
our policy, together with a copy of the new endorsement
increasing coverage to $500,000. Please let us know if
you require anything additional.
Sincerely,
Mary . Stanford, CLU, ChFC
MLS:klm
Enclosure
cc: Lawton Swan RECEIVED
MONROE COUNTY
t
Admini: !ipe Servjces /his'4. ►rt. Div.
imF
Benefits Design
Proposal Specifications
Program Evaluations
Management Workshops
Employee Communications
Financial Planning
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MISCELLANEOUS PROFESSIONAL LIABILITY POLICY THIS IS A CLAIMS MADE POLICY —READ IT CAREFULLY
•
LANDMARK INSURANCE COMPANY
!, 70 PINE STREET, NEW YORK, N.Y. 10270 ,A, i 1�
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! A CAPITAL STOCK COMPANY, HEREIN CALLED THE "COMPANY" ;y
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NOTICE: THE LIMIT OF LIABILITY AVAILABLE TO PAY JUDGEMENTS OR SETTLEMENTS SHALL BE
s; REDUCED BY AMOUNTS INCURRED FOR LEGAL DEFENSE. FURTHER NOTE THAT AMOUNTS ;
INCURRED FOR LEGAL DEFENSE SHALL BE APPLIED AGAINST THE DEDUCTIBLE AMOUNT. ;
rersons rOt hay',"' ti�a f by Surplus Lines Carrie
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RENEWAL OF:
POLICY F MI4U1 1 4 01 10
.t ,:.s Agent #0043243274 -20
Dwiyh+ E. me Coarn■ciS Zysu.rquLt.
DECLARATIONS F ' dt - , -.' ; •� etlt ;
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This insurance I9 bBUEG i ;u �� ►�, ;�
Item 1: Insured: Mary L . Stanford
;; The Florida Ei trplus Lines Law
Address: 100 Second Ave. South, Suite 200 ;r
St. Peterspurg, FL 33701
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k' Item 2. Policy Period: From: August 01,1988 To: August 01,1989 F�
at 12:01 A.M. standard time at the address of the Insured stated above r C �'' c �'
= Item 3. Limit of Liability: $250,000 Aggregate � er . t T w' N ;
c Inclusive of Defense Costs, Charges and Expenses. //i
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Item 4. Deductible: $5,000 Each Wrongful Act.
;
Item 5. Premium: $2,500 *
ii, * + 25.00 Policy Fee + 75.75 3% State TAx = 2600.75 Total
Item 6: Insured's Profession: Solely in the performance of services as a Benefit
Plan Consultant for others for a fee.
•
McCORMICK INSURANCE AGENCY, INC.
6188 FIRST AVENUE NORTH r: H ; `
Produce & Company Inc.
POST OFFICE BOX 11717
r++ Address: P.O. Box 20027
Ir t�tt ST. PETERSBURG, FLORIDA 33733
"�. PHONE:613- 384 6168 St. Petersburg, FL 33742 :
•
; By acceptance of this th ili
e agrees ,.
Application and any attachments hereto are the Insured's agreements and re p resennt bons i a ns and the
policy embodies all agreements existing betty en the In ured and the Company or any of this its
s Representatives relating to this insurance.
r i' 88/08/18 - 14039
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MISCELLANEOUS PROFESSIONAL LIABILITY
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THIS IS A CLAIMS MADE POLICY - READ IT CAREFULLY
LANDMARK INSURANCE COMPANY 'T
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70 PINE STREET NEW YORK, N.Y. 10270 s
(Herein Called The Company) LI
In consideration of the premiums paid, and in reliance upon :■
the statements in the Application attached hereto and made :A
a part hereof, and subject to the Limit of Liability stated r
in Item 3 of the Declarations and the terms and conditions r
contained herein, the Company hereby agrees as follows: A
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INSURING AGREEMENTS
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1. ERRORS AND OMISSIONS
a
A To pay on behalf of the Insured all sums which the Insured :
shall become legally obligated to pay as Damages resulting '
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from any claims first made against the Insured and reported y
W: to the Company during the Policy Period for any Wrongful r
Act of the Insured or of an other
3 y person for whose actions ;y
the Insured is legally responsible, but only if such Wrongful
Act first occurs during the Policy Period and solely in L
the conduct of the Insured's Profession as stated in Item 6 . z
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of the Declarations.
2. DEFENSE COSTS, CHARGES & EXPENSES
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With respect to such insurance as is afforded by this policy,
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A the Company shall, as part of and subject to the Limit of ,
1 Liability:
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f a) Defend any action or suit brought against the Insured ::
alleging a Wrongful Act, even if such action or suit
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is groundless, false or fraudulent; but the Insured ;
: shall not admit liability for or settle any claim :
or incur any cost or expense without the written
; . consent of the Company, and the Company shall have r
the right to make such investigation and conduct ;L
A negotiations and, with the written consent of the Insured, ■
W enter into such settlement or compromise of any claim ,:
A .
or suit as the Company deems expedient. If the Insured ,
A, refuses to consent to any settlement recommended by ,
i. the Company, the Insured shall thereafter at his own
expense negotiate or defend such claim or suit independently :
j of the Company and the liability of the Company shall ;y
't not exceed the amount for which the claim could have It
A. been settled plus the costs and expenses incurred with -'
the Company's consent up to the date of such refusal. :v
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b) Pay all expenses incurred by the Company in any action y
1 or suit brought against the Insured alleging a Wrongful
Act, and all interest on that part of the judgment y
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Company has paid, tendered or deposited in court that T
ft part of the judgment which does not exceed the Limit of y
Liability.
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c) Pay premiums on appeal bonds required in any action or
ly suit brought against the Insured alleging a Wrongful Act, r
and /or premiums on bonds to release attachments for an :
amount not in excess of the Limit of Liability, but without
any obligation to apply for or furnish any such bonds.
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• d) Pay all reasonable expenses, other than loss of earnings,
incurred by the Insured at the Company's request. v.
• s DEFINITIONS
•
R 1. Insured means the individual, partnership, corporation '
s or other entity named in Item 1 of the Declarations and shall
include any partner, director, officer or employee thereof ■
while acting within the scope of his duties as such. r
;. 2. Policy Period means the period from the effective date of
R. this policy to the expiration date or earlier cancellation
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date of this policy.
•
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R. 3. Wrongful Act means any actual or alleged breach of duty,
neglect, error, misstatement, misleading statement or ..
A omission committed solely in the conduct of the Insured's
1 Profession as stated in Item 6 of the Declarations
•
d 4. Damages means any amount that the Insured shall be legally :.
required to pay because of judgments rendered against r
W the Insured, or for settlements negotiated with the
W; written consent of the Company.
• EXCLUSIONS
This policy does not apply:
R. a) to any claim alleging fraud, dishonesty or criminal
W. acts or omissions; however, the Insured shall be
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A reimbursed for all amounts which would have been collectible
R. under this policy if such allegations are not subsequently
A proven;
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b) to any claims arising out of (1) false arrest, detention
or imprisonment; (2) libel, slander or defamation of ' T..
A character; (3) discrimination; (4) wrongful entry or
R.
!K. eviction, or invasion of any right of privacy; •
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A c) to any claim arising out of bodily injury to, or sickness,
'� disease or death of any person, or damage to or destruction . •
of any property including the loss of use thereof; •
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i d) to any claim seeking non - pecuniary relief;
e) to any claim arising out of failure to effect or maintain : r
• any insurance or bond;
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f) to any claim arising out of the gaining in fact of any •
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personal profit or advantage to which the Insured is not
legally entitled, or out of any disputes involving the
Insured's fees or charges; ■
• g) to any fines or penalties imposed by law or other matters •
which may be deemed uninsurable under the law pursuant .y
s to which this policy shall be construed; '
•
s h) to any claim arising out of breach of fiduciary duty, •
', responsibility or obligation in connection with any employee y
• benefit or pension plan;
i) to any claim brought by one Insured under this policy against
3. another Insured. •
i SPECIAL PROVISIONS •
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1. Limit of Liability.
{ The total liability of the Company for all Damages, •
defense costs, charges and expenses arising from all claims
made against the Insured during the Policy Period and inclusive
1: of the extended reporting period, if applicable, shall not ; z
7 exceed the Limit of Liability stated in Item 3 of the
Declarations. The inclusion herein of more than one Insured '
,, shall not increase the Company's Limit of Liability. :r
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2. Deductible.
4: The Company shall only be liable for those Damages, defense
W. costs, charges and expenses which are in excess of the
K ' Deductible stated in Item 4 of the Declarations. This
!' deductible shall apply to each Wrongful Act and shall be
�: borne by the Insured and remain uninsured. Claims arising T
out of the same act or out of a series of interrelated •
3
3. acts shall be considered as arising out of one Wrongful Act.
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i 3. Loss Provisions. ;.
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W The Insured shall, as a condition precendent to the 'i
W availability o t he rights provided under this policy, g ive 'r
A. written notice to the Company as soon as practicable of any
claim made against the Insured. :r
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4. Special Reporting Clause. :
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If during the Policy Period or during the extended reporting
period (if the right is exercised by the Insured in accordance ; y
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e. with Provision 5) the Insured shall become aware of any v.
occurrence which may reasonably be expected to give rise
•
to a claim against the Insured for a Wrongful Act which :
occurs during the Policy Period, and provided the Insured
•
gives written notice to the Company during the Policy
Period or the extended reporting period (if applicable)
of the nature of the occurrence and specifics of the ;�!
possible Wrongful Act, any claim which is subsequently :r
made against the Insured arising out of such Wrongful Act
shall, for the purposes of this policy, be treated as ,r
a claim made during the currency hereof. r
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1* 5. Extended Reporting Period ;r
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If the Company or the Insured shall cancel or refuse to
renew this policy, the Insured shall have the right, upon y
?: payment of an additional premium of 35% of the total annual ;'
!s: premium to a period of twelve (12) months following the
effective date of such cancellation or non - renewal in which r
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; to give written notice to the Company of claims made :
against the Insured during said twelve (12) month period r
3 for any Wrongful Act committed during the Policy Period. r t
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The rights contained in this clause shall terminate, however, :_
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1: unless written notice of such election together with the
• : additional premium due is received by the Company within
thirty (30) days of the effective date of cancellation or
?' nonrenewal. This clause shall not apply to any cancellation lt
A resulting from non - payment of premium. y
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1 GENERAL CONDITIONS '�
i;
1. This policy only applies to Wrongful Acts committed by y
w and suits brought against the Insured in the United States r
of America, its territories or possessions, or Canada.
•
2. All notices of claims applications, demands or requests :r
provided for in this policy shall be in writing and •
k addressed to Financial Services Claim Department, Landmark
A. Insurance Company, 70 Pine Street, New York, N.Y. 10270. :
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s.
, .c. 3 . The Insured shall cooperate with the Company and, upon
k the Company's request assist in settlements and ;y
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in the conduct of suits. The Insured shall attend hearings, •
f trials and depositions and shall assist in securing and • ,g
A. giving evidence and obtaining the attendance of witnesses.
3 The Insured shall not, except at his own cost, voluntarily r
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1 m any payment, assume any obligation or incur any .y
expense. is
4. No action shall lie against the Company unless, as a r
condition precendent thereto, the Insured shall have :r
fully complied with all the terms of this policy, nor :■
until the amount of the Insured's obligation to pay A
shall have been finally determined either by judgment :
•' against the Insured after actual trial and appeal or by
written agreement of the Insured and the claimant subject
to the prior written consent of the Company.
5. In the event of any payment under this policy, the Company r
? hall be subrogated to all the Insured's rights of recovery
therefore against any person or organization, and the y
Insured shall execute and deliver all instruments and papers
and do whatever else is necessary to secure such rights y
for the Company. The Insured shall do nothing to prejudice ;A
.i such rights. Any amount recovered in excess of the Company's
total payment shall be restored to the Insured, less the
cost to the Company of recovery.
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6. Such insurance as is provided under this policy shall apply r
only as excess over any other valid and collectible
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insurance.
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' 7. This policy may be cancelled by the Insured by surrender ;
3 of this policy to the Company or by giving written notice ,l:
to the Company stating when thereafter such cancellation :y
1 shall be effective. This policy may also be cancelled by y
3 the Company by mailing to the Insured by registered, certified, :s
W or other first class mail, at the Insured's address shown Y
in Item 1 of the Declarations, written notice stating when, • r
; not less than thirty (30) days thereafter, the cancellation y
W shall be effective. The mailing of such notice as aforesaid '
shall be sufficient proof of notice and this policy shall ;!
terminate at the date and hour specified in such notice.
v.
If this policy shall be cancelled by the Insured, the
Company shall retain the customary short rate proportion r
ft
of the premium hereon. If this policy shall be cancelled
by the Company, the Company shall retain the pro rata proportion
's of the premium hereon. Payment or tender of any unearned
' premium by the Company shall not be a condition precedent
f.
to the effectiveness of cancellation, but such payment shall y
be made as soon as practicable. •
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3 8. This policy shall be void if assigned or transferred without •
the written consent of the Company. If the Insured shall
ft
die or be adjudged incompetent, this policy will protect •
the Insured's legal representative as the Insured with •
respect to claims previously reported and insured under •"
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•
his policy.
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•
W 9. Bankruptcy of the Insured or of the Insured's estate shall •
`` not relieve the Company of any obligation hereunder.
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10. SERVICE OF SUIT
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It is agreed that in the event of failure of the Company , ;
to pay any amount claimed to be due hereunder, the Company,
at the request of the Insured, will submit to the
jurisdiction of a court of competent jurisdiction
within the United States. Nothing in this condition
constitutes or should be understood to constitute a waiver
of the Company's rights to commence an action in any court s
• of competent jurisdiction in the United States to remove . r
an action to a United States District Court or to seek r
i'% a transfer of a case to another court as permitted by
i the laws of the United States or of any state in the United .y
States. It is further agreed that service of process r
in such suit may be made upon Counsel, Legal Department, 'r
5 Landmark Insurance Company, 70 Pine Street, New York, N.Y. ,r
10270 or his or her representative, and that in any suit r
0. instituted against the Company upon this contract, the Company •
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will abide by the final decision of such court or of any
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appellate court in the event of an appeal.
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Further, pursuant to any statute of any state, territory,
or district of the United States which makes provision y
' therefor, the Company hereby designates the Superintendent,
'% Commissioner, or Director or Insurance, other officer y
specified for that purpose in the statute, or his or her r •
successor or successors in office as its true and lawful , r
attorney upon whom may be served any lawful process in any • t
• action, suit, or proceeding instituted by or on behalf :'
of the Insured or any beneficiary hereunder arising i
out of this contract of insurance, and hereby designates .�
the above named Counsel as the person to whom the said :r
• officer is authorized to mail such process or a true copy a
thereof.
- IN WITNESS WHEREOF, the Company has caused this policy to be
signed by its President and a Secretary and signed on the
1 Declarations page by a duly authorized representative of the
Company.
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: A tz)..A_Lx.x.., 02.,,./6 L 1.1 . t A.Q c="1..„ :
Secretary President
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ENDORSEMENT# 1
(STD #32)
• This endorsement, effective 12 :01 A.M., August 01,1988 forms a part of
policy number MPL 224 01 10
issued to Mary L. Stanford
by Landmark Insurance Company
LAWYER EXCLUSION ENDORSEMENT
In consideration of the premium charged, it is hereby understood and agreed that
this policy does not apply:
to any claim based upon or arising out of the Insured's performance of, or failure
to perform, professional services as a lawyer.
•
AUTHORIZED REPRESENTATIVE
ENDORSEMENT# 2
(STD #1)
• This endorsement, effective 12 :01 A.M., August 01,1988 forms a part of
policy number MPL 224 01 10
issued to Mary L, Stanford
•
by Landmark Insurance Company
ACTUARIAL EXCLUSION ENDORSEMENT
In consideration of the premium charged, it is hereby understood and agreed that
this policy does not apply:
to any claim arising out of any actuarial act, error, omission or assumption.
AUTHORIZED REPRESENTATIVE
ENDORSEMENT# 3
(STD #68)
This endorsement, effective 12:01 A.M. , August 01,1988 forms a part of
policy number MPL 224 01 10
issued to Mary L. Stanford
by Landmark Insurance Company
PENSION ACTUARIES AND EMPLOYEE BENEFIT
PLAN CONSULTANTS ENDORSEMENT
In consideration of the premium charged, it is understood and agreed that Exclusion "b" shall be
deleted and replaced by the following:
b) to any claims arising out of discrimination;
It is further understood and agreed that Exclusion "h" shall be deleted in its entirety.
It is also understood and agreed that the following additional exclusions shall be added to this
policy:
• This policy does not apply
1) to any claim arising out of any actual or alleged commingling of or inability or failure to
pay, collect or safeguard funds
2) to any claim arising out of the recommendation or approval or disapproval of any Trust
Investments;
3) to any claim under or arising out of the Securities Act of 1933 or The Securities
Exchange Act of 1934, the Trust Indenture Act of 1939, the Investment Advisors Act of
1940 or the State Blue Sky or Securities Law or any amendments thereto;
4) to any claim brought against the Insured, in the Insured's capacity as an Employer, based
on any violation of the Employee Retirement Income Security Act of 1974 (Public Law
93 -406) more commonly referred to as the Pension Act of 1974 or any amendments
thereto or similar provisions of any Federal, State or Local Statutory Law or Common Law;
5) to any claim arising out of the performance or non - performance of professional services
rendered to a Corporation, Association, Partnership, Joint Stock Company, Trust,
Co- operative Association, Unincorporated Organization of which the Insured or an
Employee of any Insured is a Director, Officer, or Trustee or Partner or while acting in
any Fiduciary Capacity (other than as an Independent Actuary or Employee Benefit Plan
Consultant);
6) to any claim arising out of the performance or non - performance of services as a life
insurance agent or broker.
AUTHORIZED REPRESENTATIVE
ENDORSEMENT #4
This endorsement, effective 12:01 A.M. January 18, 1989 forms a part of
policy number MPL 224 01 10
issued to Mary L. Stanford
by Landmark Insurance Company
In consideration of the additional premium of $ 1,165 ft it is hereby
understood and agreed that Item #3, Limit of Liability; or the
Declarations Page is amended to read as follows:
Limit of Liability $500,000 Aggregate inclusive of Defense Costs,
Charges and Expenses.
All other terms and conditions remain the same.
* $1,165.00 Additional Premium
34.95 3% State Tax
$1,199.95 Total
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AUTHORIZED REPRESENTATIVE
McCORMICK INSURANCE AGENCY INC
6168 FIRST AVENUE NORTH
. 110:144/61111 POST OFFICE BOX 11717
ST. PETERSBURG, FLORIDA 33733
PHONE: 813 - 384 -6168 m14039a
•
LANDMARK INSURANCE. COMPANY
•
•
ADMINISTRATIVE OFFICES
70 PINE STREET, NEW YORK, N.Y. 10270
MISCELLANEOUS PROFESSIONAL LIABILITY
APPLICATION
IF A POLICY IS ISSUED, IT WILL BE ON A CLAIMS -MADE BASIS
NOTICE: THE POLICY PROVIDES THAT THE LIMIT OF LIABILITY AVAILABLE TO PAY JUDGEMENTS OR
SETTLEMENTS SHALL BE REDUCED BY AMOUNTS INCURRED FOR LEGAL DEFENSE. FURTHER NOTE
THAT AMOUNTS INCURRED FOR LEGAL DEFENSE SHALL BE APPLIED AGAINST THE DEDUCTIBLE
AMOUNT.
1. NAME OF APPLICANT Mary L. Stanford, CLU, ChFC
' F
ADDRESS: 100 Second Avenue South, Suite 200
St. Petersburg, Florida 33701
2. LIMIT OF LIABILITY DESIRED:
$250,000 X $500,000
$1,000,000 Other
3. DEDUCTIBLE:
$1,000 $2,500 $5,000 X
$10,000 Other
4. Please describe in detail the professional activities for which coverage is desired:
Employee Benefits Consulting; includes life insurance, health insurance; dental,
disability, cafeteria plans, and related products. Primary clients are private and
Public employers, typically 100 to 2500 employees. Consulting consists of evaluating
benefits design, preparing specifications for rebidding coverages, analysis of proposals
and recommendation for product /insurer. Fee basis only, advice and counsel. Sell no
products or administrative services.
5. Is the applicant engaged in any business or profession other than as described in Item 4? no
please attach an explanation and estimated receipts. If yes,
Page 1 of 5
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6. List the total gross receipts for the past three years derived from those activities in Question 4. In addition,
please list projected receipts for the current year.
YEAR AMOUNT
a) Current Projected 1988 $ 75,nnn (client development, non - billable; and production,
b) 1987 $ 132 nnn billable, expected)
c) 1986 $ 121,000 (Revenues billed for Siver firm. Applicant
d) 1985 $ 105,000 on salary at $50,000 /year; 100% production
only, no time allocated to client development',
7. For the receipts listed in question 6a), please give the approximate percentage derived from each of the
activities listed in Question 4:
ACTIVITY % OF 6a) RECEIPTS
Employee Benefits 100 ok
•
Consulting only, no ok
products or administrative o�
services are sold. oho
8. Applicant is: Corporation Partnership Individual X
9. Year Established: 1988
10. Is the Applicant Firm controlled, owned or associated with any other firm, corporation or company? .
YES NO X . If yes, attach an explanation. Are any activities listed in Question 4 provided to such
business enterprise? YES NO
11. a) Number of principals, partners, officers and professional employees directly engaged in providing services
to clients: one (applicant)
b) Number of non - professional employees (clerks, secretaries, etc.): one
Page 2 of 5
•
12. Please provide the following:
Name in full of ALL
Partners /Principals/ PROFESSIONAL DATE HOW LONG AS
Key Employees. QUALIFICATIONS QUALIFIED H PRACTICE PRINCIPAL
Mary L. Stanford Fla licensed 1978 10 years (1) 4 months (1)
life and health,
Chartered Life 1981
•
Underwriter,
Chartered 1984
Financial
Consultant
(1) 1978 -1983 Life & Health agent (sales) - Prudential Insurance Company;
1983 -1988 Senior Employee Benefits Consultant and Vice - President of Siver
Insurance Management Consultants;
March 1988 Resigned from Siver to start own Employee Benefits Consulting firm
13. To what professional association(s) does the Applicant Firm belong?
National Association of Life Undewriters: Florida and St. Petersburg Association of
Life Underwriters; West Coast Employee Benefits Council; Society of CLU and ChFC
14. Please include a list of Applicant Firm's five (5) largest jobs or projects during the past three (3) years. Please
give, in detail: 1) project/client name; 2) the nature of the services performed for the client; and 3) the revenues
obtained from those services.
City of Hollywood, remarket arouo life and health plan (soecifications. analysis and
recommendation), $20,000
• Florida Polk County. remarket group life and health plan. dental plan, $19,500
Dew Cadillac, remarket group life and health plan, $10,000
.f . k env' - . - '.n f - '. - s - f' . - . - .. - . 'fi ^. '.n - market
life and health plans, and flexible benefits, open contract - $100 /hour
Carl Zanger, Esouire, New York - prepare soecifications for life insurance. analyze
proposals, and recommend best cost /benefits, $6,000
15. Does the Applicant Firm use a written contract with clients?
X In all cases Sometimes
Never
Please attach a copy of your standard contract. (retainer or project letter)
•
16. What percentage of the Applicant Firm's business involves subcontracting of work to others ?none *o does
the Applicant Firm provide professional services to business entities in which it retains an ownership interest
Yes No X . If yes, please explain.
* Speripli7erl services not nrnvided by applicant (e.g., actuarial and legal) are
referred to these specialists if such services are necessary support for the
ronsulting assignment. Actuary /attorney performs work, bills applicant, applicant
passes cost through to client without mark -up. Such work is requested typically by
telephnne nr letter, and is rarely necessary and considered a support resource.
There is no contractual arrangement.
Page 3 of 5
17. Has any similar insurance ever been declined or cancelled? Yes X (if yes, attach explanation.) No
Association Groups (NALU, LUSO, IAFP, ICFP) declined because consulting is fee only
basis, no commissions. Their underwriting requirements do not permit fee only.
18. Is similar insurance currently in force? Yes No
If yes, please provide: Covered 1983 to April 30, 1988 by Professional Liability with,Siver
Insurance Management Consultants
Name of Carrier: Nat i nna 1 I Ini nn thrn ,gh F h n Rrnkerage, New Ynrk
policy number MCPL1946313
Expiration Date: n8-7R -RR - F k G ariv i Seri that Nat i nna 1 t In i nn i s not arrept i no new
business in Florida and refused to continue coverage on
Limit: 1 , nnn, nnn Deductible: 5, nnn Premium: unknnwn applicant as new
business.
Length of time coverage has been in force: Si nre nR -28-R3
19. Attach current annual report and descriptive or promotional materials.
Resume on applicant; client services, sample specification and report.
20. Have any of the individuals listed in question No. 12 ever been the subject of disciplinary action by authorities
as a result of their professional activities? If yes, please explain.
Nn
21. Does any person to be insured have knowledge or information of any act, error or omission which might
reasonably be expected to give rise to a claim against him. YES No _X__ (if so, attach full particulars).
22. Attach list and status of all errors and omissions claims made against any proposed Insured(s) during the past
three years. If None, please check here: NONE X for applicant. No claims against Slyer
coverage in the past 5 years.
23. It is agreed with respect to questions # 20, 21 and 22 above, that if such knowledge or information exists any
claim or action arising therefrom is excluded from this proposed coverage.
acceptable
THIS APPLICATION DOES NOT BIND THE APPLICANT OR THE COMPANY TO COMPLETE THE INSURANCE
BUT IT IS AGREED THAT THIS FORM SHALL BE THE BASIS OF THE CONTRACT SHOULD A POLICY BE
ISSUED, AND IT WILL BE ATTACHED TO AND MADE A PART OF THE POLICY. THE UNDERSIGNED APPLI-
CANT DECLARES THAT TO THE BEST OF HIS KNOWLEDGE THE STATEMENTS SET FORTH IN THIS APPLICA-
TION ARE TRUE. THE APPLICANT FURTHER DECLARES THAT IF THE INFORMATION SUPPLIED ON THIS
APPLICATION CHANGES BETWEEN THE DATE OF THIS APPLICATION AND THE TIME WHEN THE POLICY
IS ISSUED, THE APPLICANT WILL IMMEDIATELY NOTIFY THE COMPANY OF SUCH CHANGE.
Page 4 of 5
NOTICE TO NEW YORK APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD
ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING
ANY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CON-
' CERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
PRODUCER: APPLICANT'S / ,
SIGNATURE / I
L`,;
ADDREE3: TITLE a,_
DATE: _ s /__ - •
NEW YORK APPLICANTS: PLEASE READ THE FOLLOWING STATEMENT CAREFULLY AND SIGN BELOW
WHERE INDICATED. IF A POLICY IS ISSUED, NEW YORK INSURANCE DEPARTMENT REGULATIONS REQUIRE
THAT THIS SIGNED STATEMENT BE ATTACHED TO THE POLICY.
The Insured hereby acknowledges that he /she /it is aware that the limit of liability contained in this policy shall be
reduced, and may be completely exhausted, by the costs of legal defense and, in such event, the Insurer shall
not be liable for the costs of legal defense or for the amount of any judgement or settlement to the extent that
such exceeds the limit of liability of this policy.
The Insured hereby further acknowledges that he /sheet is aware that legal defense costs that are incurred shall
be applied against the deductible amount.
INSURED:
BY:
TITLE:
DATE:
Page 5 of 5
PEKSXON kCTUAUXES AND EMPt-OYEB BENE =
PLAN CO]f Q SV��'LEPQNTA Am. cwrzoN
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1) List the name of al oxners, partners, directors, officers and employed actuaries or
consultants:
YEARS /N m PIMIZ8IOHAL
NAME • ? �_ rss/taoo oar
Mary L. Stanford Owner -- 10 Total* Yes West Coast Employee
Consultant Benefits CoUncil;
Society of CLU &
*1978 -83 Life & Hee th Agent (Sales) Prudential Ins. Co. ChFC
1983 -88 Senior Emp oyee Benefits Consultant and VP of Nat'l Assoc. of
Siver Insu ance Management Consultants, St. Pete, FL Lif Underwriters
3/88 Founded St.nf rc� & � ance Consultants St.Petersburg Assoc.
2) Total n u m b e r oft a E m p l o y e d S a I c t u a r i s s 0 o f Life U n d e r w r.
b) Employed Actuaries 0
c Employed Pension Consultants 0
d All Other Office Staff 1 Secretary
Fees
3) Give details of o •
Atioaa: Expected Fees produced while
Service Perctittagl! 19 8 - 89 employed by Siver firm
a) Data Processin• other than .� �_... 1987 1986 1985
retirement or •up Plans • 0 0
b) Pension & waif.•e fund consulting
c) l'ensiott & welf : , e actuarial &
. administrative ork by type of
plan (e.g. Def , d Benefit) 0 ' 0
Type (i) 0 0
(ii) 0 0
(iii) 3 0
d) Group Modical LtIourance P1anS 75% $ 557, 0 $
e) Iasuranca /Management consulting n
f) Actuarial IIV 1 for or on behalf
of Life Insurance companies 0 D
g) Other opet:ati to
Consulting 25% .$18$0p0 000/2600
Life Ins., ental, Disability, l f't '
4) Give �h f t i f , R @flile z i/ns � P `ceaat B Ctti�tr 1 ' handles: .0 0
Fu1ly� Insured Split 3udsd N - Usured
t) Defined Benefi . 0 • 0 i
b) Defined Contri tion 0 0 0
5) Describe the five rgeet; Retirement Plans currently handled by applicant (inoitjde
gross revenue, typ of plan and number of lived). None
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