Insurance Policy Application

Please answer all questions completely on this application. Type or print answers clearly. If there is insufficient space to complete an answer, continue in the “Additional Details” section at the bottom of this application or on a separate sheet and indicate the applicable question number. If any questions are considered “not applicable,” please explain why the question is not applicable unless the reason is readily apparent. This application and all supplemental applications must be signed and dated by a principal of the firm. “Principal” means any partner, officer or owner of Applicant. “Applicant” means any entity or any individual for whom coverage is requested.

Notice to the Applicant: This is an application for a “Claims Made Policy”. Subject to all its terms, conditions, exclusions, and Limits of Liability, the policy provides insurance coverage only for Claims arising out of the rendition of Professional Services, which are first, made against the Insured and reported in writing to the Company during the Policy Period or any Extended Reporting Period.

The Limits of Liability under the policy will be reduced, and may be exhausted, by any Claims Expenses, as defined in the policy, that are paid by the Company on behalf of an Insured.