Form 440-5379 "Attestation of Errors and Omissions Insurance" - Oregon

What Is Form 440-5379?

This is a legal form that was released by the Oregon Department of Consumer and Business Services - a government authority operating within Oregon. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2018;
  • The latest edition provided by the Oregon Department of Consumer and Business Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form 440-5379 by clicking the link below or browse more documents and templates provided by the Oregon Department of Consumer and Business Services.

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Download Form 440-5379 "Attestation of Errors and Omissions Insurance" - Oregon

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Oregon Department of Consumer and Business Services
Division of Financial Regulation
350 Winter St. NE, Room 410, Salem, Oregon 97301-3881
Mailing address: P.O. Box 14480, Salem, OR 97309-0445
503-378-4140  Fax: 503-947-7862
http://dfr.oregon.gov
ATTESTATION OF ERRORS AND OMISSIONS INSURANCE
Pursuant to ORS 59.175(5); OAR 441-175-0185
This form may be used in conjunction with a policy declaration page or certificate of liability
insurance to demonstrate compliance with ORS 59.175(5) under OAR 441-175-0185. This form may
also be used to inform the division of a change in insurance.
All fields must be completed
New
Amended
Name of Applicant or Licensee:
1.
Licensee IA No. or CRD No.:
2.
Name of Insurer:
3.
Policy Number:
Policy Amount:
4.
Start Date of Policy:
End Date of Policy:
6.
CERTIFICATION
I certify that I have made reasonable efforts to verify the accuracy and completeness of the
information contained in this attestation and the applicable policy documents. I affirm that the
errors and omissions coverage attested to has been in continuous effect throughout the policy
period, covers persons affiliated with the Investment Advisor who perform investment advisory
functions in Oregon, and that this attestation will be amended if there are any material changes to
the coverage, including to the insurer.
I am duly authorized by the issuer to sign this certification.
Signature:
Printed Name and Title:
Date:
Send attestation and proof of insurance under OAR 441-175-0185 via e-mail to
dfr.repreg@oregon.gov
fax: 503-947-7862; or mail to
Division of Financial Regulation
P.O. Box 14480, Salem, OR 97309
440-5379 (6/18/COM)
Oregon Department of Consumer and Business Services
Division of Financial Regulation
350 Winter St. NE, Room 410, Salem, Oregon 97301-3881
Mailing address: P.O. Box 14480, Salem, OR 97309-0445
503-378-4140  Fax: 503-947-7862
http://dfr.oregon.gov
ATTESTATION OF ERRORS AND OMISSIONS INSURANCE
Pursuant to ORS 59.175(5); OAR 441-175-0185
This form may be used in conjunction with a policy declaration page or certificate of liability
insurance to demonstrate compliance with ORS 59.175(5) under OAR 441-175-0185. This form may
also be used to inform the division of a change in insurance.
All fields must be completed
New
Amended
Name of Applicant or Licensee:
1.
Licensee IA No. or CRD No.:
2.
Name of Insurer:
3.
Policy Number:
Policy Amount:
4.
Start Date of Policy:
End Date of Policy:
6.
CERTIFICATION
I certify that I have made reasonable efforts to verify the accuracy and completeness of the
information contained in this attestation and the applicable policy documents. I affirm that the
errors and omissions coverage attested to has been in continuous effect throughout the policy
period, covers persons affiliated with the Investment Advisor who perform investment advisory
functions in Oregon, and that this attestation will be amended if there are any material changes to
the coverage, including to the insurer.
I am duly authorized by the issuer to sign this certification.
Signature:
Printed Name and Title:
Date:
Send attestation and proof of insurance under OAR 441-175-0185 via e-mail to
dfr.repreg@oregon.gov
fax: 503-947-7862; or mail to
Division of Financial Regulation
P.O. Box 14480, Salem, OR 97309
440-5379 (6/18/COM)