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LAWYERS PROFESSIONAL LIABILITY INSURANCERENEWAL APPLICATIONMedmarc Casualty Insurance Company PO Box 10809 Chantilly, VA 20153-0809 800.356.6886 703.652.1300 Fax 703.652.1389NOTICE: This professional liability coverage is provided on a Claims Made and Reported basis. Only claims that are first made against the insuredand reported to the Company during the policy term are covered, subject to the policy provisions.Applicant Instructions: Please complete all questions, noting N/A where not applicable. Enclose a copy of the law firm’s letterhead. The applicationmust be dated and signed by a partner, officer or owner of the firm.1.Name (Primary Firm Name):Is this a d/b/a (doing business as) name? YesNoIf yes, provide legal name:Policy Number:Renewal Date:Contact Person:Email Address:Street Address:2.3.4.5.City:County:Office Phone:Office Fax:State:ZIP:Website:a. Have any lawyers left the firm since completion of the last application?If yes, please provide on a separate sheet the name(s) of the lawyer(s) who left and the terminationdate for each, if not previously reported.YesNob. Have any lawyers joined the firm since completion of the last application?If yes, please complete an Add Lawyer Information Supplement for each new hire not previously reported.YesNoc. Have any lawyer(s) changed to full-time or to part-time since completion of the last application?If yes, please provide on a separate sheet the name(s) of the lawyer(s) and average weekly hours.YesNoa. changed its procedures for docket/diary control? . Yesb. filed any fee suits against clients?. Yesc. changed its conflict of interest procedures? . Yesd. changed its back-up lawyer? . Yese. implemented or changed its web site? . Yesf. increased or decreased the number of support staff? . YesIf yes to any of the above, please explain on a separate sheet.NoNoNoNoNoNoSince completion of the last application, has the firm:Since completion of the last application, has an office location been added, or has the applicant entered into anoffice sharing arrangement? . YesIf yes, please explain on a separate sheet.For any entity other than civic, charitable, or public benefit non-profit organization, does any lawyer:a. have a new position as a director/officer/trustee or partner? . Yesb. have a change in any previously reported position or equity? . Yesc. have any new or changed managerial/fiduciary control? . Yesd. have any new or changed ownership or management? . Yese. act as an employee of any organization other than the applicant? . Yesf. provide any professional services other than as a lawyer? . YesIf yes, please complete the Outside Interests Supplement6.NoNoNoNoNoNoNoGross Revenue for the most recent calendar year:LC 9002 (9/14) 2014 Medmarc Casualty Insurance CompanyPage 1 of 5

7.Since completion of the last application were any services performed in the areas of:IPO, Bond Private Placement Syndication, SecuritiesEntertainment Client or IndustryEnvironmentForeign AdoptionsIf yes, please provide details on firm letterhead.8.9.Class ActionCopyright, Patent or TrademarkOil and GasConstruction Defect (Plaintiff)Since completion of the last application, has the firm been adjudicated bankrupt or insolvent or subject to a pendingbankruptcy petition? If yes, please explain on a separate sheet.YesNoAREA OF PRACTICEIndicate the percentage of time devoted to the following types of practice during the past 12 months and complete theArea of Practice Supplement, if needed (MUST TOTAL 100%). If there has been no change in the past 12 months,you may indicate that here and not complete the chart below.No ChangeCOLUMN AAd Valorem Tax – CommercialAd Valorem Tax – ResidentialAdministrative LawAdoptionsAntitrust Trade RegulationsAppellate - Non ionCorporation FormationCorporate GeneralDivorce - Marital Assets 2MDivorce - Marital Assets 2M to 5MDivorce - Marital Assets 5MElder LawEnvironmentalERISAFamily Law (other than Divorce)ForeclosuresFiduciaryHealthHousing CourtImmigrationInternationalInvestment Cnsling/Money MgtLabor – Employee / UnionLabor – ManagementLocal Government / MunicipalM&A -Combined Assets 2MM&A-Combined Assets 2M to 5MM&A - Combined Assets 5MCOLUMN BPercentage%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%Oil and GasPublic UtilitiesSocial SecurityTAX-Commercial PreparationTAX-Individual PreparationTAX – OpinionsVenture CapitalWater LawDefenseAdmiraltyArbitration / MediationBI/PICivil Rights/EmploymentClass Action / Mass TortCommercial LitigationCriminalCriminal - AppellateInsurance CompanyLegal MalpracticeMedical MalpracticeProduct LiabilityWorkers ate PlacementsSecurities – FederalSecurities – StateLC 9002 (9/14) 2014 Medmarc Casualty Insurance CompanyCOLUMN PlaintiffAdmiraltyBI/PI PlaintiffCivil Rights / EmploymentClass Action / Mass TortCommercial LitigationLegal MalpracticeMedical MalpracticeProduct LiabilityWorkers g/Financial InstitutionsEntertainmentEstate Planning - Assets 2MEstate Planning-Assets 2M to 5MEstate Planning - Assets 5MProbateReal Estate – CommercialReal Estate DevelopmentReal Estate – Limited PartnershipsReal Estate - ResidentialReal Estate SyndicationsWills and Trusts%%%%%%%%%%%%%%Complete Supplement Application for all AOPsin Column C aboveOther%Other%Other%Total %100%Page 2 of 5

10. Since completion of the last application, has any lawyer covered under the policy been the subject of any investigationor disciplinary action regarding their license to practice? If yes, please explain on a separate sheet.YesNo11. Since completion of the last application, has any lawyer covered under the policy been refused admission to the baror any bar association, court, or administrative agency? If yes, please explain on a separate sheet.YesNoYesNoYesNo12. During the current policy year, have any claims or suits been made against the firm, its predecessor firms, or any ofthe lawyers proposed for this insurance that have not been previously reported to this CompanyIf yes, please complete the Claim Information Supplement13. Is any member of the firm aware of any act, error, omission, or specific circumstances involving a particular person orentity which could reasonably be expected to result in a professional liability claim against the firm, any past or presentlawyers in the firm, or any predecessor firm? If yes, please explain on a separate sheet.Fraud Warning – I acknowledge the applicable fraud warning for my state as shown on the Fraud Warning Notices Page.Consent to Conditions of Consideration of the Application for InsuranceI accept the following conditions during the processing and consideration of my application—regardless of whether or not I am grantedinsurance—and for the duration of the insurance which may be issued to me:To the fullest extent permitted by law, I extend absolute immunity to, and release ProAssurance, its directors, officers, agents, employees and otherauthorized representatives from any and all liability for any acts pertaining to my application for insurance, including ultimate cancellation,rejection, or approval for insurance, and any communications, reports, records, statements, documents, or disclosures, including otherwiseprivileged or confidential information, made or given in good faith with respect to such application.Signature of Partner, Officer or Owner of Applicant Firm:Print or Type Name:Date:Title:Important: Incomplete or incorrect information could require retroactive upward premium adjustment and, in the event of a claim, could lead toa denial of coverage. The following is an Authorization to Release Information which requires your signature. Please read it carefully.Authorization to Release InformationI, the undersigned hereby authorize my present and prior professional liability carriers, (including ProAssurance all affiliates), any and all attorneyswho have represented me in connection with any claim of professional liability, and any other individuals, associations or entities havinginformation regarding me, to release to ProAssurance upon its request, any information which in the judgment of any such person noted above,may have bearing upon my acceptability to ProAssurance as a professional liability risk, including but not limited to closed, pending or anticipatedclaims, underwriting or other information.I hereby release and agree to hold harmless all persons or organizations, their agents, servants, and employees, ProAssurance, its directors, officers,employees and agents from any liability arising from releasing the above information, notwithstanding the fact that there may be errors, omissions,or mistakes contained in such released information.I further agree that ProAssurance and all persons and organizations described above may rely upon a photo copy of this Authorization, whichshall be of equal validity with the signed original.I hereby declare and represent that the foregoing statements and particulars are, to the best of my knowledge and recollection, complete and that Ihave not willfully concealed or misrepresented any material fact or circumstance concerning this insurance or the subject thereof:Signature of Partner, Officer or Owner of Applicant Firm:Print or Type Name:LC 9002 (9/14) 2014 Medmarc Casualty Insurance CompanyDate:Title:Page 3 of 5

For Agent’s Use Only (Where Required By Law)Name of :Signature:Date::Fraud Warning NoticesPlease read the fraud warning notice for your state:General Fraud Warning – Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submitsan application or files a claim containing a false or deceptive statement is guilty of insurance fraud.Alabama Fraud Warning – Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or whoknowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines orconfinement in prison, or any combination thereof.Arizona Fraud Warning – For your protection, Arizona law requires the following statement to appear on this form. Any person whoknowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.California Fraud Warning – For your protection, California law requires the following to appear on this form: any person who knowinglypresents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in stateprison.Colorado Fraud Warning – It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurancecompany for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial ofinsurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, ormisleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholderor claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division ofInsurance within the Department of Regulatory Agencies.District of Columbia Fraud Warning – It is a crime to provide false or misleading information to an insurer for the purpose ofdefrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurancebenefits if false information materially related to a claim was provided by the applicant.Delaware Fraud Warning – Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statementof claim containing any false, incomplete or misleading information is guilty of a felony.Florida Fraud Warning – Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claimor an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.Idaho Fraud Warning – Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statementcontaining any false, incomplete, or misleading information is guilty of a felony.Kentucky Fraud Warning – Any person who knowingly and with intent to defraud any insurance company or other person files anapplication for insurance containing any materially false information or conceals, for the purpose of misleading, informationconcerning any fact material thereto commits a fraudulent insurance act, which is a crime.Maine Fraud Warning – It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for thepurpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.Maryland Fraud Warning – Any person who knowingly or willfully presents a false or fraudulent claim for payment for a loss or benefitor who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to finesand confinement in prison.LC 9002 (9/14) 2014 Medmarc Casualty Insurance CompanyPage 4 of 5

Massachusetts Fraud Warning – Any person who knowingly and with intent to defraud any insurance company or another person filesan application for insurance or statement of claim containing any materially false information, or conceals for the purpose ofmisleading information concerning any fact material thereto, may be committing a fraudulent insurance act, which may be a crime andmay subject the person to criminal and civil penalties.Minnesota Fraud Warning – A person who submits an application or files a claim with intent to defraud or helps commit a fraud againstan insurer is guilty of a crime.New Hampshire Fraud Warning – Any person who, with a purpose to injure, defraud or deceive any insurance company, files astatement of claim containing any false, incomplete, or misleading information is subject to prosecution and punishment for insurancefraud, as provided in RSA 638:20.New Jersey Fraud Warning – Any person who includes any false or misleading information on an application for an insurance policyis subject to criminal and civil penalties.New Mexico Fraud Warning – Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit orknowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminalpenalties.New York Fraud Warning – Any person who knowingly and with intent to defraud any insurance company or other person files anapplication for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading,information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime shall also be subject to a civilpenalty not to exceed five thousand dollars and the stated value of the claim for each such violation.Ohio Fraud Warning – Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submitsan application or files a claim containing a false or deceptive statement is guilty of insurance fraud.Oklahoma Fraud Warning – Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim forthe proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.Oregon Fraud Warning – Any person who, with an intent to knowingly defraud or knowingly facilitate a fraud against an insurer, submitsan application or files a claim containing a false or deceptive statement or a material fact, may be guilty of insurance fraud.Pennsylvania Fraud Warning – Any person who knowingly and with intent to defraud any insurance company or other person filesan application for insurance or statement of claim containing any materially false information or conceals for the purpose ofmisleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects suchperson to criminal and civil penalties.Tennessee Fraud Warning – It is a crime to knowingly provide false, incomplete, or misleading information to an insurance companyfor the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.Vermont Fraud Warning – Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submitsan application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.Virginia Fraud Warning – It is a crime to knowingly provide false, incomplete, or misleading information to an insurance companyfor the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.Washington Fraud Warning – It is a crime to knowingly provide false, incomplete or misleading information to an insurance companyfor the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.West Virginia Fraud Warning – Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit orknowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinementin prison.LC 9002 (9/14) 2014 Medmarc Casualty Insurance CompanyPage 5 of 5

PROFESSIONAL LIABILITY INSURANCEADD LAWYER INFORMATION SUPPLEMENTMedmarc Casualty Insurance Company PO Box 10809 Chantilly, VA 20153-0809 800.356.6886 703.652.1300 Fax 703.652.13891.New Lawyer:New Lawyer Positionin this Firm *Average HoursPer weekName of Insured Firm:State BarAdmissionsYear AdmittedYears inPracticeArea of PracticeSpecialtyDate of Hire/* Positions: “O” Owner/Officer/Partner“A” Associate/Employed LawyerExact Dates AssociatedFrom ( MDY) to (MDY)Name of Prior Firm//-////-////-//“OC” Of CounselProfessional Liability Carrier/“IC” Independent ContractorPrimary Area ofPracticePositionin Firm *2.Have you or your prior firm purchased an Extended Reporting Period Endorsement (ERP) on your behalf? . YesIf yes: ERP Effective from:to3.Does your new firm (Insured Firm listed above) wish to provide prior acts coverage? (Prior acts coverage means coveragefor acts or omissions that occurred prior to the Date of Hire listed in Question 1. above.) . YesIf yes, what retroactive date is being requested? Requested Retroactive Date: (Please attachproof of insurance showing continuous coverage from this date to the date of hire.)4.Are you an employee of any organization other than the Insured Firm listed above? . YesIf yes, please explain:5.Within the last 6 years, have you acted as a director, officer, partner or trustee for, or exercised any form of managerial orfiduciary control over, any business enterprise other than the Insured Firm? . YesIf yes, please complete the Outside Interests Supplement.6.Have you ever been the subject of any investigation or disciplinary action regarding your license to practice law? . YesIf yes, please explain on a separate sheet.7.Have you ever had any professional liability insurance declined, cancelled, refused to renew, or accepted only onspecial terms? If yes, please explain on a separate sheet. . Yes8.Have you ever been refused admission to the bar or any bar association, court or administrative agency? . YesIf yes, please explain on a separate sheet.9.In the past five (5) years have there been any claims or suits made against you regarding services you performed or failedto perform? If yes, please complete a Claim Information Supplement. . YesNoNoNoNoNoNoNoNo10. Are you aware of:a.b.c.d.any circumstance, act, error or omission which could be the basis of a claim or suit? . Yesany potential malpractice claim or suit reported to a previous insurance carrier? . Yesany adverse judgment which could be the basis of a claim or suit? . Yesany missed statute of limitations? . YesLC 9011 (9/14) 2014 Medmarc Casualty Insurance CompanyNoNoNoNoPage 1 of 5

e.f.any dissatisfaction with representation? . Yesany client, client representative or lawyer that has made an oral or written threat of filing a lawsuit or filing a grievancewith a regulatory board? . YesIf yes to any of a. through f. above, please provide details on a separate sheet, and advise the number of potential claims.11. Have all claims, potential claims and incidents been reported to your current or former professional liability insurer? . YesNoNoNoIf no, please note: To avoid loss of coverage, it is imperative that all known claims and/or circumstances,acts, errors or omissions that could result in a professional liability claim against you, your current firm, itspredecessor firms or any lawyers in the firm be reported to your current insurer within the time period specified inyour current policy.12. Have the firm’s areas of practice changed with your addition to the firm? . YesNoIf yes, please explain:13. Have you continued representation of any clients or cases from your prior law firm? . Yesa. Has each case been reviewed for potential conflicts of interest? . Yesb. Has each case been entered into all docket control systems? . Yesc. Has each case been reviewed for potential claims? . Yesd. Has each client been notified of the change in law firm? . Yese. Has each client received an updated engagement/retention letter? . YesIf no to any of the above, please explain on a separate sheet.NoNoNoNoNoNo14. As to all former clients for which you have entered an appearance, and who are no longer your clients,has a substitution of lawyer or withdrawal of appearance been completed? . YesIf no, please explain on a separate sheet.No15. During the past five (5) years, have you practiced in any of the following areas of law: Securities, Bond work, IntellectualProperty, Financial Institutions (Regulatory), International (other than immigration), Antitrust, ERISA? . YesIf yes, please describe on a separate sheet the nature of your practice in these areas.No16. During the past ten (10) years, have you had any equity interest or served as director, officer, partner, general counsel,or member of any committee of any entity which is a past or present client? . YesIf yes, please complete the Outside Interests Supplement.NoFraud Warning – I acknowledge the applicable fraud warning for my state as shown on the Fraud Warning Notices Page.Consent to Conditions of Consideration of the Application for InsuranceI accept the following conditions during the processing and consideration of my application—regardless of whether or not I am grantedinsurance—and for the duration of the insurance which may be issued to me:To the fullest extent permitted by law, I extend absolute immunity to, and release ProAssurance, its directors, officers, agents, employees and otherauthorized representatives from any and all liability for any acts pertaining to my application for insurance, including ultimate cancellation,rejection, or approval for insurance, and any communications, reports, records, statements, documents, or disclosures, including otherwiseprivileged or confidential information, made or given in good faith with respect to such application.Signature of New Lawyer:Date:Signature of Partner, Officer or Owner of Applicant Firm:Title:Date:LC 9011 (9/14) 2014 Medmarc Casualty Insurance CompanyPage 2 of 5

Important: Incomplete or incorrect information could require retroactive upward premium adjustment and, in the event of a claim, could lead toa denial of coverage. The following is an Authorization to Release Information which requires your signature. Please read it carefully.Authorization to Release InformationI, the undersigned hereby authorize my present and prior professional liability carriers, (including ProAssurance all affiliates), any and all attorneyswho have represented me in connection with any claim of professional liability, and any other individuals, associations or entities havinginformation regarding me, to release to ProAssurance upon its request, any information which in the judgment of any such person noted above,may have bearing upon my acceptability to ProAssurance as a professional liability risk, including but not limited to closed, pending or anticipatedclaims, underwriting or other information.I hereby release and agree to hold harmless all persons or organizations, their agents, servants, and employees, ProAssurance, its directors, officers,employees and agents from any liability arising from releasing the above information, notwithstanding the fact that there may be errors, omissions,or mistakes contained in such released information.I further agree that ProAssurance and all persons and organizations described above may rely upon a photo copy of this Authorization, whichshall be of equal validity with the signed original.I hereby declare and represent that the foregoing statements and particulars are, to the best of my knowledge and recollection, complete and that Ihave not willfully concealed or misrepresented any material fact or circumstance concerning this insurance or the subject thereof:Signature of New Lawyer:Date:For Agent’s Use Only (Where Required By Law)Name of :Signature:Date::Fraud Warning NoticesPlease read the fraud warning notice for your state:General Fraud Warning – Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submitsan application or files a claim containing a false or deceptive statement is guilty of insurance fraud.Alabama Fraud Warning – Any person who knowingly presents a false or fraudulent claim for payment of a l

LAWYERS PROFESSIONAL LIABILITY INSURANCE RENEWAL APPLICATION Medmarc Casualty Insurance Company PO Box 10809 Chantilly, VA 20153-0809 800.356.6886 703.652.1300 Fax 703.652.1389 NOTICE: This professional liability coverage is provided on a Claims Made and Reported basis. Only claims that are first made against the insured