Travelers SelectOne
for Investment Advisors and Funds
Independent Review Committee Liability
T HIS I S AN AP P LI C AT IO N FO R A C L AIM S M AD E PO LI CY
Independent Review Committee Individual Coverage
Limit of Liability: $
Retention: $
Investment Fund and/or Investment Fund Manager
Indemnification Coverage
Limit of Liability: $
Retention: $
INSTRUCTIONS FOR COMPLETION OF APPLICATION
Please attach the following documents with this Application:
(i)
The most recent audited financial statements together with any notes and schedule for the Investment Fund Manager;
(ii) Copies of all contractual agreements, including all contracts between the Independent Review Committee and the Investment
Fund and/or the Investment Fund Manager relating to Independent Review Committee indemnification of the members of the
Independent Review Committee;
(iii) Copies of the resumes and/or complete biographies of all members of the Independent Review Committee;
(iv) A copy of the Independent Review Committee’s charter and mandate; and
(v) A copy of the most recent report filed by the Independent Review Committee as required by Section 4.4 of National Instrument
81-107, Independent Review Committee for Investment Funds.
NOTE: As used in this application, the term “Subsidiary” includes limited liability companies.
Please answer questions accordingly.
SECTION I
1.
GENERAL INFORMATION
This section must be completed in full
Name of Independent Review Committee:
Address:
2.
Date of Formation of the Independent Review Committee:
3.
Name of Investment Fund Manager:
Address:
4.
Please indicate the total assets under administration (AUM) for each Investment Fund Manager. If more space is required, please
attach a separate sheet.
Name of Investment Fund Manager
AUM ($)
Investment Fund Family Name
5.
Does the Investment Fund Manager invest in any securities of its parent company or any of its affiliates or any other company in
which any of the aforementioned entities have any financial interest? If yes, please provide details.
Yes
No
6.
Has any provincial or territorial securities commission or any self-regulatory organization or equivalent organization conducted any
inspection, investigation or examination of the Investment Fund Manager (including any of its directors, officers or employees)
within the past five (5) years for any actual or alleged breach of any securities law or regulation, including any order, policy, rulings
or decisions of any securities regulator, in respect of prohibited investments under Part 4 of National Instrument 81-102, Mutual
Funds?
Yes
No
IAF (IRC).APP (06-06-07)
©Travelers Insurance Company of Canada
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Travelers SelectOne
for Investment Advisors and Funds
7.
During the last five (5) years, has any member of the Independent Review Committee been involved as a defendant, party or
witness, either personally or on behalf of any organization, in: If Yes, to (i) and/or (ii) please provide details.
(i) any civil, criminal, regulatory or administrative proceeding in respect of any
actual or alleged breach of any securities law or regulation, including any
order, policy, rulings or decisions of any securities authority; or
Yes
No
(ii) any settlement, agreement or sanction relating to any actual or alleged
violation of any securities law or regulation, including any order, policy,
rulings or decisions of any securities regulator or self-regulatory organization?
Yes
No
8.
Does the Investment Fund Manager manage any Investment Fund (as defined in National Instrument 81-107), which is a hedge
fund, or a labour sponsored fund? If yes, please provide details
Yes
No
Please note that hedge funds and labour sponsored funds are not Investment Funds under the proposed Policy unless
added by endorsement to the proposed Policy.
9.
Please provide the name of the public accounting firm that prepares the Investment Fund Manager’s independent audited financial
statements.
(i) Has the Investment Fund Manager changed its public accounting firm in the last five (5) years?
Yes
No
If yes, please provide details.
SECTION II
INDEPENDENT REVIEW COMMITTEE LIABILITY
This section must be completed in full
1.
Please provide the names of all Independent Review Committee members:
2.
Please provide the name of the Chairperson of the IRC.
3.
Is the mandate for the Independent Review Committee broader than that, which is required by National Instrument 81-107,
Independent Review Committee for Investment Funds? If yes, please provide details.
Yes
No
4.
Are any members of the Independent Review Committee currently acting as a member of any other Independent Review
Committees? If yes, please provide details.
Yes
No
5.
Has any member of the Independent Review Committee held any director, officer or trustee position of the Fund Manager,
Investment Fund or Parent Company? If yes, please provide details.
Yes
No
IMPORTANT: DO NOT ANSWER QUESTIONS 6 THROUGH 8 OF THIS SECTION IF YOU ARE RENEWING TRAVELERS
INDEPENDENT REVIEW COMMITTEE LIABILITY INSURANCE COVERAGE.
6.
Has there been, or is there now pending, any written demand for monetary damages or non-monetary relief, civil or criminal
proceeding, formal administrative or regulatory proceeding, or arbitration proceeding, against any person proposed for this
insurance?
Yes
No
If yes, please provide details, including the date, a brief description, and the damages sought or settlement paid, of such claim, and
the current status if pending.
7.
Has any claim, or notice of circumstances which could reasonably give rise to a claim, been reported to any previous or existing
insurer providing coverage for the Independent Review Committee? If yes, provide details.
Yes
No
8.
Does any person proposed for this insurance have any knowledge or information of any fact, circumstance or situation, which could
reasonably give, rise to a claim that would fall within the scope of the proposed insurance?
Yes
No
If yes, provide details.
IAF (IRC).APP (06-06-07)
©Travelers Insurance Company of Canada
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Travelers SelectOne
for Investment Advisors and Funds
It is agreed that this policy shall not afford coverage with respect to any claim arising from any such fact, circumstance or
situation to the extent the claim is against any person proposed for this insurance who knew of such fact, circumstance or
situation prior to binding or issuing the proposed policy.
AUTHORIZATION
The undersigned persons represent, after inquiry, that the statements and representations set forth in this application, and all
materials submitted to or requested by the Insurer in conjunction with this application, are true. The undersigned authorized
representatives acknowledge that these statements, representations, and materials are relied on by the Insurer and that they
are deemed material to the acceptance of the risk or hazard assumed by the Insurer under the insurance applied for, should
the insurance be effected. The undersigned authorized representatives agree that if the information supplied via this
application changes between the date of this application and the effective date of any insurance effected pursuant to this
application, the undersigned will immediately notify the Insurer of such changes, and the Insurer may withdraw or modify any
outstanding quotations and/or authorization or agreement to effect the insurance.
Signing of this application does not obligate the undersigned or the Insurer to m,effect the insurance, but it is agreed that all
materials submitted to or requested by the Insurer in conjunction with this application, are hereby incorporated by reference
into this application and made a part hereof. It is further agreed that this application and all materials submitted to or
requested by the Insurer in conjunction with this application are the basis of and are deemed attached to and incorporated
into the policy effected pursuant to this application. The insurer is hereby authorized to make any investigation and inquiry in
connection with this application.
Signature of Chairman of Independent Review Committee
Date Signed
Print Name
Signature of Investment Fund Manager, President or Chairperson
Date Signed
Print Name
IAF (IRC).APP (06-06-07)
©Travelers Insurance Company of Canada
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