Connecticut Supplement State-Registered Investment Advisers Application Form Page 2
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3Pending Actions
The undersigned certifies, on behalf of the above Applicant, that the Applicant is not the subject of any
pending civil litigation or any securities-related complaints, actions or proceedings (whether civil,
criminal, administrative or involving arbitration, including updates) which have not been reported on
Form ADV and are otherwise reportable.
The undersigned certifies, on behalf of the above Applicant, that the Applicant is the subject of pending
civil litigation or a securities-related complaint, action or proceeding (whether civil, criminal,
administrative or involving arbitration, including updates) which has not been reported on Form ADV
and is otherwise reportable.
Attach a Separate Schedule Providing Details and Enclosing a Copy of all Dispositional
Documents.
Undertakings Regarding Client Referrals; Unregistered Activity
The undersigned undertakes, on behalf of the above Applicant, that: 1) before directly or indirectly
offering an individual additional compensation for client referrals, the Applicant will ensure that such
individual is registered as an investment adviser agent under the Connecticut Uniform Securities Act
before the Applicant pays compensation to such individual; and 2) the Applicant will not transact
business as an investment adviser in or from Connecticut until effectively registered as an investment
adviser in this state.
Workers’ Compensation Coverage
Section 31-286a(b) of the Connecticut General Statutes provides that "[o]n and after October 1, 1986,
no state department, board or agency may renew a license or permit to operate a business in this state
unless the applicant first presents sufficient evidence of current compliance with the workers’
compensation requirements of section 31-284."
Subsection (d) of Section 3l-286a states that "[f]or purposes of this section, ’sufficient evidence’ means
(1) a certificate of self-insurance issued by a workers’ compensation commissioner pursuant to Section
3l-284, or (2) a certificate of compliance issued by the insurance commissioner pursuant to Section 3l-
286, or (3) a certificate of insurance issued by any stock or mutual insurance company or mutual
association authorized to write workers’ compensation insurance in this state or its agent."
If you have questions about how Section 31-286a or Section 31-284 of the Connecticut General
Statutes applies to you, please direct them to your attorney or to the Workers’ Compensation
Commission at (860) 493-1500 rather than to the Department of Banking.
The Applicant represents as follows (only check one box):
The Applicant will not be operating a business in Connecticut within the meaning of Section 3l-
286a(b) of the Connecticut General Statutes and is not subject to Section 3l-284 of the Connecticut
General Statutes.
The Applicant will be operating a business in Connecticut within the meaning of Section 3l-286a(b)
of the Connecticut General Statutes and has attached a copy of the certificate required by that
section.
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