Applicant Information

Date Established*
Business Address*
Owner Name*
Do you publish an employee handbook?
Does the Applicant have employees located in any of the following States or the District of Columbia?
Does the Applicant have employees located in any of the following States or the District of Columbia?
  Yes No
CA
DC
LA
TX
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Operational Questions

Complete the following chart providing the requested financial information: Indicate the following as it relates to the Applicant’s fiscal year end (FYE)

Most Recent FYE*
Prior FYE*
$
Previous 12 months
$
Previous 12 months
$
Previous 12 months
$
Previous 12 months
In the next 12 months (or during the past 24 months) is the Applicant contemplating (or has the Applicant completed or been in the process of completing) the following:*
In the next 12 months (or during the past 24 months) is the Applicant contemplating (or has the Applicant completed or been in the process of completing) the following:
  Yes No
Any actual or proposed merger, acquisition, or divestiture?
Any creation of a new business, subsidiary, or division?
Any registration for a public offering or a private placement of securities (stocks or bonds)?
Any reorganization or arrangement with creditors under federal or state law?
Any branch, location, facility, office, or subsidiary closings, consolidations, or layoffs?
After diligent inquiry and reasonable investigation, does the applicant, or any predecessor in business or any of the past or present partners, Officers, Directors, or employees have any reasonable basis to believe that the applicant or any predecessor in business or any of the past or present partners, Officers, Directors or employees possess knowledge of any circumstances, incidents, or situations during the past five years which have resulted or which may result in a loss or a claim being made against the applicant, any of the past or present partners, Officers, Directors or employees or former employees of the applicant? *

Professional Liability Questions

List loan activity during last 12 months (if start-up provide annual projections):

Number of Loans Originated:

Dollar Amount:

Residential

$

Commercial

$

Construction

$

Other

$
Do you service loans?

Number of Loans Serviced:

Dollar Amount:

Residential

$

Commercial

$

Construction

$

Other

$
Do you have a warehouse line of credit?

What percentage of loans are:

Regarding All applicable lending laws, does the Applicant:
Regarding All applicable lending laws, does the Applicant:
  Yes No
Have procedures in place to ensure compliance?
Have any known violations?

Bond Questions

Are there any Subsidiaries (over 50% ownership)?*
Are Mortgage Broker services provided?*
Are Mortgage Banker services provided?*
Is there a formal, planned program requiring the segregation of duties so that no single transaction can be fully controlled from origination to posting by one person? *
Are bank accounts reconciled by someone not authorized to deposit or withdraw? *
Are countersignature of checks (including escrow accounts) required? *
Does the Applicant verify the validity of funds transfer or payment requests with out-of-band authentication procedures?*
Out-of-band means using a different means of communication from the funds transfer or payment request. For example, if the request comes in via email the applicant will verify the validity of the request by calling the requesting party back at a pre-approved phone number.

D&O Questions

  Yes No
Does the Applicant currently file, or does it anticipate filing in the next 12 months, any documents with the Securities and Exchange Commission or similar foreign authority regarding any equity or debt securities?
Is any shareholder a trust that qualified as an Employee Stock Ownership Plan under ERISA or holds securities for the benefit of employees?
Are there currently outstanding loans to any Director or Officer?
Is the Applicant currently (or has it been in the past 24 months) in violation of, or has it received an amendment to any debt covenant?

EPL Coverage

Does the Applicant have employees located in any of the following States or the District of Columbia?
Does the Applicant have employees located in any of the following States or the District of Columbia?
  Yes No
CA
DC
LA
TX

Employee turnover figures:

Current Fiscal Year

Last Fiscal Year

Voluntary/Resignations:

Involuntary (excluding layoffs/downsizing):

Layoffs/Downsizing:

        Total Number of Terminations:

        Total Number of Employees:

  Yes No
Does the Applicant conduct training for employees on issues of discrimination, sexual harassment, and abusive conduct prevention?
Do you conduct Background/Criminal Record Checks?
Do you publish an Employee Handbook?
Does your Employee Handbook include, or do you have formal written guidelines, policies and procedures that are provided to all employees related to the following?*
Does your Employee Handbook include, or do you have formal written guidelines, policies and procedures that are provided to all employees related to the following?
  Yes No
EEO/Non-Discrimination
Sexual and Other Workplace Harassment
Disabled Employees & Accommodations
Employment At-Will
Required Federal & State Leave Policies
Wage & Hour and Overtime Administration
  Yes No
Prior to employee terminations does the Applicant consult with Human Resources personnel or an attorney with experience in employment law?
Does the Applicant provide severance packages to involuntarily terminated or laid off employees?
If yes, does the severance agreement include a waiver or release of an employee’s rights to bring claim against the Applicant?
If yes, did any of these employees refuse to accept the severance and not sign the waiver?
Does the Applicant have written policies or procedures outlining employee conduct and complaints involving harassment or discrimination of third parties?
  Yes No
Does the Applicant have an HR department or designated HR manager?
Does the Applicant have written policies or procedures for handling complaints?
Does the Applicant have written job descriptions and written, regular performance evaluations?

Cyber Liability

  Yes No
Do you take regular, at-least weekly, back-ups of your important data and store off-site or disconnected from your network?
Have you installed and do you regularly update anti-malware/virus software on all your computers and laptops?
Do you change all default passwords on new devices and require regular mandatory password updates for all accounts?
Do you have a process in place to regularly patch your systems and applications?
Do you configure and use a firewall to protect all your devices, particularly those that connect to public or other untrusted Wi-Fi networks?
Do you control access to your data through user accounts, and review who should have administrative access on a regular basis?
Do you have a business continuity plan and review such at least annually?
Do you have multi-factor authentication (MFA) enabled for your IT administrators and banking facilities?
Do you have a data retention policy?
Do you accept credit cards or debit cards for payment?
Are you PCI compliant?*
For applicants that have revenues over $20,000,000, please answer the following:
For applicants that have revenues over $20,000,000, please answer the following:
  Yes No
Do you have a written privacy policy that has been reviewed by a suitably qualified lawyer?
Do you have a disaster recovery / incident response plan in place that takes account of loss of functionality as a result of a hack?
Do you have an individual in your organization specifically assigned the responsibility of information security, such as a Chief Information Security Officer (CISO)?

Fraud Warnings

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Notice to Alabama residents: “Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines, or confinement in prison, or any combination thereof.”

Notice to Alaska residents: “A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information may be prosecuted under state law.”

Notice to Arizona residents: “For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.”

Notice to Arkansas residents: “Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.”

Notice to California residents: “For your protection California law requires the following to appear on this form. Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.”

Notice to Colorado residents: “It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.”

Notice to Delaware residents: “Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony.”

Notice to District of Columbia residents: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

Notice to Florida residents: “Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.”

Notice to Idaho residents: “Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony.”

Notice to Indiana residents: “A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or misleading information commits a felony.”

Notice to Kansas residents: “Any person who commits a fraudulent insurance act is guilty of a crime and may be subject to restitution, fines and confinement in prison. A “fraudulent insurance act” means an act committed by any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral, or telephonic communication or statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto.”

Notice to Kentucky residents: “Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.”

Notice to Louisiana residents: “Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.”

Notice to Maine residents: “It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.”

Notice to Maryland residents: “Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.”

Notice to Minnesota residents: “A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.”

6

SGA 2022

Notice to New Hampshire residents: “Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.”

Notice to New Jersey residents: “Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.” “Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.”

Notice to New Mexico residents: “Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.”

Notice to New York residents: “Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.”

Notice to Ohio residents: “Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.”

Notice to Oklahoma residents: “WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.”

Notice to Pennsylvania residents: “Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.”

Notice to Rhode Island residents: “Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.”

Notice to Tennessee residents: “It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.”

Notice to Texas residents: “Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.”

Notice to Vermont residents: “Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.”

Notice to Virginia residents: “It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.”

Notice to Washington residents: “It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.”

Notice to West Virginia residents: “Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.”

Important Notice and Signature

The applicant declares that the statements set forth herein are true. The applicant agrees that if the information supplied on this application changes between the date of this application and the effective date of the insurance, the applicant will, in order for the information to be accurate on the effective date of the insurance, immediately notify the underwriter of such changes, and the underwriter may withdraw or modify any outstanding quotations or authorizations or agreements to bind the insurance.


Signing of this application does not bind the applicant or the underwriters to complete the insurance, but it is agreed that this application shall be the basis of the contract should a policy be issued, and it will become part of the policy.


All written statements and materials furnished to underwriters in conjunction with this application are hereby incorporated by reference into this application and made a part hereof.

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Important Notice and Signature - Copy

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