FORENSIC LITIGATION CONSULTANTS PROFESSIONAL LIABILITY
(This is an application for claims made coverage)

A) Please type answers to all questions, leaving no blank spaces.
B) The application must be signed and dated.
C) When answering questions, please use a separate attachment if space provided is insufficient.
D) - PLEASE TYPE -
Applicant is
 
3 a) Is your forensic work done on a full or part-time basis?
If Part-time, do you work full-time?
Annual income from full-time occupation
Gross income from full-time occupation for past three (3) years:
c) Can you confirm you have all required licenses and qualifications to carry out the areas of your expertise?
d) I hereby affirm that all required licenses for the practice of my profession under this insurance will remain current (in force) during the currency of this policy for which I am applying. I further understand and agree that I shall have no coverage for any professional services rendered at any time that any required or applicable license is not valid or in good standing.
10. Does the Applicant maintain any other type of professional liability insurance?
If Yes, please furnish for the past three (3) years:
11. a) Have any claims or suits been made during the past ten years against the Applicant, or any person now a principal or owner of the Applicant, or any predecessor entity or any prior entity owned or previously owned by a current principal or owner of the Applicant either as an individual or as an expert witness or forensic consultant:
11. b) Upon inquiry of all personnel, is the Applicant, or any employee, manager or owner of the Applicant, aware of any circumstance, incident or situation, which may result in a claim?
11. c) Have all claims and circumstances requiring a response in questions 11a) and 11b) already been reported to and accepted by a current or past Insurer?
12. Has any similar insurance for the Applicant or any person now a principal or owner of the Applicant, or any predecessor entity or any prior entity owned or previously owned by a current principal or owner of the Applicant either as an individual or as an expert witness or forensic consultant ever been canceled or declined or refused renewal?
13. Limits of Liability Requested:
Deductible Requested:
 

Please send a copy of resume(s).

I hereby declare that the above statements and particulars are true, and that I have not suppressed or misstated any material facts.  At the present time, I have no reason to anticipate any claim being brought against me for any act, error or omission on my part, other than as stated above, and agree that this Proposal Form shall be the basis of the contract between me and the Underwriters and shall be deemed a part thereof.

This Proposal Form duly completed, together with any supplementary information, must be signed in ink by the Applicant.  A signed copy will be attached to and form part of the Policy or Certificate, if issued.  Completion of this Proposal Form does not bind or obligate the Applicant or Underwriters to complete this insurance.

© 1989 Complete Equity Markets, Inc.        A86-6279