70 York Street, Suite 1100 Toronto, ON M5J 1S9 Phone: (416) 214-2555 Fax: (416) 214-9597
FIDUCIARY BOND APPLICATION AND INDEMNITY AGREEMENT TYPE OF BOND: NAME OF BROKER: BROKER KNOWS APPLICANT SINCE: EFFECTIVE DATE OF BOND: BOND AMOUNT: $
COMPLETE IF APPLICANT(S) IS AN INDIVIDUAL NAME OF APPLICANT(S): Name: 1. Mailing Address and email address SIN No.
2.
3.
COMPLETE IF APPLICANT IS A CORPORATION/LLC/LLP NAME OF APPLICANT: Full Address: E-mail Address: Website Address: Organized date: (dd/mm/yy): under laws of (Dom.) (Prov.) (State) Name of President: Name of Secretary: Name(s) of Major Shareholders: Name of Vice-President: Name of Treasurer: ( %) ( %) ( %) ( %)
Trisura Fiduciary Bond App and Indemnity – April 2007
TYPE OF BOND: 1. 2. 3.
ADMINISTRATION [ ] FOREIGN EXECUTOR [
COMMITTEE [ ]
]
GUARDIANSHIP [
]
Occupation of Applicant (if retired, previous occupation): Business address of Applicant: Give names and address of two persons for reference: Name Occupation
State full address
4.
Has application for this bond been made to any other company (if yes, why not executed) Have you or any other person provided a bond for this estate previously? (If yes, state details) Is application to replace and existing bond (If yes, why?) Is applicant replacing a previous administrator/executor/committee? (If yes, please give reason) Relationship of Applicant to decedent or incompetent: Applicant’s share in estate:
[
] YES
[
] NO
5.
[
] YES
[
] NO
6.
[
] YES
[
} NO
7.
[
] YES
[
} NO
8. 9.
10. Are you indebted to the Estate? (If yes, give full particulars)
[
] YES
[
] NO
11. Name and address of solicitor you will employ: 12. Does the decedent or incompetent have a will? (If yes, please attach copy) 13. Name and Address of deceased or incompetent: [ ] YES [ ] NO
Date of Death or Date Declared Incompetent:
If Incompetent, age of individual: 14. If deceased, did the deceased die: [ } Testate [ ] Intestate 15. Court and location where application/administration is being filed (if applicable attach copy of application to court): 16. BENEFICIARIES: Name Age Relationship to Deceased Address
INVENTORY OF ESTATE – COMPLETE SCHEDULE “A” – “INVENTORY OF ESTATE” TO FORM PART OF THIS APPLICATION. *PLEASE ATTACH: PERSONAL NET WORTH STATEMENT, INDEPENDENT LEGAL ADVICE, PROMISE TO PAY AND ALL RELATED CORRESPONDENCE, AFFIDAVITS and COURT DOCUMENTATION.
The undersigned hereby declare(s) that all the information provided herein is to the best of my/our knowledge true, complete and correct and understand it will be used by Trisura Guarantee Insurance Company to determine credit worthiness. The undersigned further consent(s) to the Trisura Guarantee Insurance Company making any enquiries it deems necessary to reach a decision on this application, and consent(s) to the disclosure at any time of any credit information about me/us to any credit reporting agency or to any one with whom I/we have financial relations. That Trisura Guarantee Insurance Company may complete any blanks left or correct any errors in completing any blanks, herein or in the said foregoing statement, and such insertions or corrections shall be prima facie correct. INDEMNITY AGREEMENT WHEREAS, the undersigned have applied to TRISURA GUARANTEE INSURANCE COMPANY (hereinafter referred to as the “Surety”) for certain surety bonds (hereinafter referred to as the “Bonds”, which term shall include all extensions, renewals, substitutions and modifications thereto). NOW THEREFORE, in consideration of the issue of Bonds, whether past, present and future, by the Surety or procured by the Surety on behalf of the undersigned or of the Surety refraining from cancelling such Bonds and of the sum of Two Dollars and other good and valuable consideration paid by the Surety to each of the undersigned (the receipt and sufficiency of which are hereby acknowledged) the undersigned hereby jointly and severally agree as follows: 1. The undersigned undertake to indemnify the Surety in full for any loss or damages that it may suffer arising from the issue of one or several Bonds, or arising from a decision of the Surety not to issue any Bond, or arising from any default by the undersigned under the present agreement. The present undertaking includes, without limitation, the obligation of the undersigned to reimburse to the Surety all sums which it might be called upon to pay: A. as a result of a judgment, arbitration award or settlement; B. as damages of any nature, including punitive and exemplary damages, as the case may be; C. in respect of any claim, liability or loss; D. as expenditure, costs or fees that it may incur, including the cost of internal or external adjusters and consultants; E. in satisfaction of judicial and extra-judicial fees and disbursements of the Surety’s counsel on a solicitor and client basis and legal fees of claimants’ counsel; F. as administration costs related to claims under Bonds and under this agreement. 2. The undersigned undertake to pay to the Surety: A. the initial premium for the issue of any Bond, in conformity with the Surety’s tariff in force, or such other tariff as may be agreed upon with the undersigned; and B. thereafter, any additional or other premium, in conformity with the Surety’s tariff in force or such other tariff as may be agreed upon with the undersigned until such time as the Surety receives proof to its satisfaction, confirming its complete release from all Bonds issued by it, and from the renewal or extension of such Bonds.
3. In order to permit the Surety to meet its obligations under the Bonds, the undersigned undertake to advance to the Surety upon demand, funds or satisfactory guarantees sufficient to allow the Surety to perform any or all of its obligations under the Bonds, which could be subject to indemnification under the terms of the present agreement, even before any payment has been made by the Surety to a third party. Without limiting the generality of the foregoing, the undersigned undertake to advance funds or furnish guarantees, as soon as the Surety establishes or increases a reserve with respect to a claim or a situation relating to any Bonds, up to the amount of such reserve which will be established by the Surety in its sole discretion. 4. The undersigned acknowledge that the Surety will have the right, in its sole and entire discretion whether to pay, settle or contest any claim under a Bond without any obligation to consult or advise the undersigned in advance of so doing. The undersigned acknowledge their obligation to indemnify the Surety in virtue of the present agreement, upon presentation by the Surety of a release or a copy of a cheque or any other proof of payment, which will be deemed to be complete proof of the amount paid and of the Surety’s right to make such payment as a result of the issue of the Bonds and, consequently, its right to demand reimbursement from the undersigned under the terms of the present agreement.
5.
The undersigned hereby renounce the benefits of division and discussion.
6. This agreement shall extend to and be binding upon the heirs, executors, administrators, successors and assigns of the undersigned. 7. All of the terms and conditions of the present agreement are for the benefit of: A. any predecessors or successors or assigns of the Surety, including as a result of mergers, name changes, acquisitions of portfolios, or otherwise, and B. any surety, joint or several, any re-insurance company and any other surety procured by the Surety upon the request of the undersigned to issue a Bond or Bonds, whether or not such Bond or Bonds are issued by the Surety or whether or not the surety retains any interest in any such Bond or Bonds.
8. The present agreement will be interpreted in accordance with the laws in force in the Province of Ontario and the laws of Canada applicable therein.
CONSENT TO SURETY'S OBTAINING INFORMATION Each of the Indemnitors (a) authorizes the Surety to obtain any credit or other information concerning the affairs and operations of each of the Indemnitors (including any “personal information”, as defined by the Personal Information Protection and Electronic Documents Act (Canada) and other applicable personal information laws) and any transaction between or among any of the Indemnitors from any banks, depositories, sureties, obligees of the Bonds, materialmen, supply houses, credit reporting agencies, brokers or other persons (collectively, “Sources”); expressly instructs all such Sources to furnish such information to the Surety (and for greater certainty, instructs any broker(s) to release to the Surety any information relating to any Bond(s) or Bonding Facility); and consents to the collection, use and disclosure by the Surety of any personal information about such Indemnitor for the purposes of the entering into, administration and enforcement of this Agreement and any Bond(s).
(b)
(c)
IN WITNESS WHEREOF, the undersigned have executed and sealed this Indemnity Agreement this day of , 20 . PERSONAL INDEMNITORS SIGN HEREUNDER WITNESS Typewritten Name Signature of Witness Address Signed at Typewritten Name Signature of personal indemnitor Address Social Insurance Number INDEMNITORS
Typewritten Name Signature of Witness Address
Signed at Typewritten Name Signature of personal indemnitor Address Social Insurance Number
CORPORATE INDEMNITORS SIGN HEREUNDER AND AFFIX SEAL Name of Corporation: Address of Corporation: Name in block letters (Authorized Officer) - Title Signature of Authorized Officer
I HAVE AUTHORITY TO BIND THE CORPORATION LLC/LLP
Name in block letters (Authorized Officer) - Title Signature of Authorized Officer I HAVE AUTHORITY TO BIND THE CORPORATION LLC/LLP
Name of Corporation: Address of Corporation: Name in block letters (Authorized Officer) - Title Signature of Authorized Officer
I HAVE AUTHORITY TO BIND THE CORPORATION LLC/LLP
Name in block letters (Authorized Officer) - Title Signature of Authorized Officer I HAVE AUTHORITY TO BIND THE CORPORATION LLC/LLP
PROMISE TO PAY TO: RE: TRISURA GUARANTEE INSURANCE COMPANY ESTATE OF
In consideration of the TRISURA GUARANTEE INSURANCE COMPANY (the “Company”) issuing an Administration Bond Statutory Guardian/Committee Bond on behalf of (name of Applicant) for the above captioned estate, I, hereby irrevocable undertake as follows: 1. To pay to the Company upon execution of this Promise to Pay the sum of $ as premium with respect to the bond for the first term, and a further sum of $ to be paid in advance for each term thereafter until the Company shall have been, by the undersigned, furnished with good and sufficient evidence satisfactory to the Company of the termination of all liability under said bond. That, as Administrator Statutory Guardian / Committee of the estate herein, I will move expeditiously to administer this estate and finalize all estate matters as soon as legally possible and, thereafter, forthwith arrange for the cancellation of Trisura Guarantee Insurance Company Administration Statutory Guardian/ Committee Bond that has been filed with (name of Court) Court in this matter. day of ,
2.
IN WITNESS WHEREOF the undersigned has executed this Promise to Pay this 20 .
Witness
Name in block Letters
Signature
NOTE: Where the bond is terminated or the amount is reduced during the first year there shall be no premium refund. Where the bond is terminated during the second or subsequent year a premium refund will be made on a pro rata basis. Where the duration of the suretyship is for more than a period of one (1) year, premiums may be requested in advance for each additional year of suretyship.
NOTE: PLEASE HAVE COMPLETED WHERE BOND AMOUNT EXCEEDS $150,000.00 ACKNOWLEDGEMENT AND CERTIFICATE OF INDEPENDENT LEGAL ADVICE Any masculine reference shall be considered masculine, feminine or plural, where applicable. This is to certify on this day of 20 , I (name of solicitor) of the
of
in the Province of
, who is known to me, this day
personally appeared before me. I satisfied myself by examination that he was aware of his personal guarantee in favour of Trisura Guarantee Insurance Company and understood the contents of a certain instrument in writing entitled FIDUCIARY BOND APPLICATION AND INDEMNITY AGREEMENT which is attached hereto. I fully explained the nature and effect of the document to him. He has stated to me and I am satisfied that he fully understands the nature and effect of the document and that he executed it freely and voluntarily and not under any undue influence exercised by any other party. Subsequently, in my presence, he executed the said Application which is dated . I signed as a witness to his execution of the said Application. Give at day of , in the Province of A.D. , this under my hand and seal office.
A Notary Public and Solicitor in and for the Province of Name of Notary Public or Solicitor: Address: (please print) I HEREBY acknowledge that fully explained the nature and effect of the document. I confirm that I understand the nature and effect of the document and that I have executed it freely and voluntarily.
Name of applicant: (please print)
Signature of applicant
70 York Street, Suite 1100 Toronto, ON M5J 1S9 Phone: (416) 214-2555 Phone: (416) 214-2555
PERSONAL WORTH STATEMENT
To be completed by each Applicant that is an Individual
Legal Name of individual: (Please put alias name in brackets) Business Address: Physical Residence Address: Home Phone # Driver’s License # or S.I.N.:
STATEMENT OF ASSETS AND LIABILITIES AS OF CURRENT ASSETS CURRENT LIABILITIES
Accounts Payable (Schedule "D”) Bank Loan (Schedule ”D”) Loans Payable (Schedule ”D”) Taxes Due Non-Registered Stocks, Bonds etc. (Schedule “A”) Pension RSP or other Registered Funds Accounts & Notes Receivable (Schedule “B”) Life Insurance (Cash Surrender Value) Total of Other Current Assets Listing of Other Current Assets Total of Other Current Liabilities Listing of Other Current Liabilities
(DD/MM/YYYY)
Cash Specify all Banks & Branch Addresses
TOTAL CURRENT ASSETS FIXED ASSETS
Real Estate (Schedule “C”) Total of Other Personal Property and Fixed Assets Listing of Other Personal Property and Fixed Assets
TOTAL CURRENT LIABILITIES DEFERRED LIABILITIES
Mortgages on Real Estate (Schedule “C”) Total of other Deferred Liabilities Listing of other Deferred Liabilities
TOTAL ASSETS PERSONAL NET WORTH
(Total Assets – Total Liabilities)
TOTAL LIABILITIES
SCHEDULE “A” - NON-REGISTERED STOCKS, BONDS, ETC. NAME OF SECURITY NO. OF SHARES PAR VALUE MARKET VALUE IF PLEDGED, TO WHOM AND FOR WHAT PURPOSE
SCHEDULE “B” - ACCOUNTS & NOTES RECEIVABLE FROM WHOM AMOUNT DATE DUE TERMS
SCHEDULE “C” – REAL ESTATE LOCATION AND DESCRIPTION OF PROPERTY (1) Principal Residence: IN WHOSE NAME TITLE DATE OF PURCHASE PURCHASE PRICE FAIR MARKET VALUE AMOUNT OF MORTGAGE FINANCIAL INSTITUTIO N
NOTE: If assets are held jointly, please have the joint owner sign below
SCHEDULE “D” – ACCOUNTS PAYABLE, BANK LOAN & LOANS PAYABLE TO WHOM AMOUNT DATE DUE TERMS
The Undersigned hereby declare(s) that all the information provided herein and on the accompanying statements is to the best of my/our knowledge true, complete and correct and understand it will be used by the Surety to determine credit worthiness. The Undersigned further consent(s) to the Surety making any inquiries it deems necessary to reach a decision on this application, and consent(s) to the disclosure at ay time of any credit information about me/us to any credit reporting agency or to any one with whom I/we have financial relations. Witness (Signature) (Print Name) Address Phone No. Date Signed Individual (Signature) (Print Name)