Poulton Associates, Inc. :: Insurance Risk Management

Fiduciary Liability Quick Quote Application

Get a free quote on fiduciary liability insurance coverage! Use this application to provide us with the information we will need.

If you wish, you may read some articles about why you may need this coverage .

Please contact us if you have questions.

Your Contact Information

Information on your application will be electronically encrypted for confidentiality and security.
* Denotes Required Field.

*	Name:	*	E-mail:
*	Address:		2nd Address:
*	City:	*	State:
*	Zip:	*	Phone:
	Fax:		Company:

Your Plan Information

Employer (Plan Sponsor) Name:
Employer (Plan Sponsor) Address:
Would like a premium estimate on coverage amount:
Please insert limit desired if not shown above:	$

All Premium estimates are offered contingent on receipt / acceptable review of origional completed application.

Official Name(s) or employee benefit trust or plan (as it appears on the Form 5500)	Annual Contribution, or, for welfare plans, annual expense	Asset Value	Number of Participants

Please provide this same information for additional plans, if necessary: 1000 char max

Pension Plan Investment Administrator: (i.e. Smith Barney, The Principal, XYZ Bank, etc)

Employer Identification Number (EIN): (Dept. of Treasury/DOL Form 5500 or Form 5500 C/R pg 1 b)

SIC/Business Code: (Dept. of Treasury/DOL Form 5500 or Form 5500 C/R, pg 1 d)

Nature of your Business: (i.e. machine parts manufacturer, consulting engineers, etc.)

Other Comments

Are there any other kinds of insurance you need(e.g., Directors & Officers, Employee Dishonesty, etc.)?
If so, please list them, along with any comments or questions you may have.
We would especially like your feedback on this form's ease of use.