Mediators Professional Liability

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ARBITRATORS, HEARING OFFICERS AND MEDIATORS

PROFESSIONAL LIABILITY INSURANCE AND COMERCIAL GENERAL LIABILITY INSURANCE

(This is an application for a claims-made policy.)

1. Full Name of Assured: *

2. Address (MUST be a Physical Address): *

(City) *

(State) *

(Zip) *

Phone Number:

Fax Number:

Email Address:

Mailing Address:

3. If Assured is not an individual, specify whether:

corporation

partnership

other (explain) other (explain)

4. List branch offices, if any:

5. Describe the purpose, general activities, and functions of your operation and date established (use a separate page if necessary):

Not all activities listed are covered by this insurance. Please refer to policy wording

6. Name of Executive Director or Chief Administrator, if any:

7. Names of individuals conducting arbitration proceedings or dispute resolution services (mediation) or hearing officer services, including all arbitrators/hearing officers/mediators employed by or working in conjunction with the Assured (use a separate page if necessary):

	Name	Arbitrator, Hearing Officer or Mediator	PT or FT (PT is 20 hrs. a week or less)	10 Cases or Less Annually (Y/N)
.	Name	Arbitrator, Hearing Officer or Mediator	PT or FT (PT is 20 hrs. a week or less)	10 Cases or Less Annually (Y/N)
.	Name	Arbitrator, Hearing Officer or Mediator	PT or FT (PT is 20 hrs. a week or less)	10 Cases or Less Annually (Y/N)
.	Name	Arbitrator, Hearing Officer or Mediator	PT or FT (PT is 20 hrs. a week or less)	10 Cases or Less Annually (Y/N)
.	Name	Arbitrator, Hearing Officer or Mediator	PT or FT (PT is 20 hrs. a week or less)	10 Cases or Less Annually (Y/N)
.	Name	Arbitrator, Hearing Officer or Mediator	PT or FT (PT is 20 hrs. a week or less)	10 Cases or Less Annually (Y/N)

8. State the total number of cases and/or files handled or processed annually (an estimate may be given if accurate count is not available):

9. Classify the subject matter of each case arbitrated/mediated by the Assured during the past 12 months (i.e. community disputes; divorce). In the event the Assured has operated for less than 12 months, state the estimated number of cases the Assured will handle in each category during the first 12 months of operation (use a separate page if necessary):

	Category	Number of Cases
.	Category	Number of Cases
.	Category	Number of Cases

10. State whether the numbers specified in your answer to Questions 8 & 9 are estimated figures:

Yes

No

11. Has any professional liability claim or suit been made against the Assured or any individual listed in Question 7 arising out of the conduct of arbitration proceedings or dispute resolution services or hearing officers services?

Yes

No

If Yes, give name of person involved, name of claimant, date and disposition of the case:

12. Does the Assured or any individual listed in Question 7 know of any circumstance, act, error, omission, or personal injury that could result in a claim or suit against him/her or the Assured named in the application?

Yes

No

If Yes, give name of possible claimant, date of account and other details:

13. Describe the management of the Assured's operation (Sole Proprietor, Trustees, Board of Directors, Titles of Officers, etc.):

14. Does the Applicant or Applicant Firm conduct Arbitration Proceedings or Dispute Resolution Service or Hearing Officer Services in countries other than the US, its Territories or possessions, or Canada?

Yes

No

If Yes, please list the countries.

15. Does the Applicant or Applicant Firm require coverage to extend to acts committed overseas subject to the suit or the threat of a suit being filed being brought within the US, its territories or possessions, or Canada?

Yes

No

Cyber Liability Section - OPTIONAL

1. Do you comply with all applicable regulatory and industry supported privacy and security standards and frameworks that are applicable to your industry, including PCI data to your business?

Yes

No

2. Does applicant use intrusion detection software, firewall protection and anti-virus systems to detect/prevent unauthorized access to internal networks and computer systems?

Yes

No

3. Does applicant have a written procedure to communicate a privacy breach to state authorities and affected parties?

Yes

No

4. Has the Applicant given written notice under the provisions of any prior or current cyber risk, media or network security policy of specific facts or circumstances which may give or have given rise to a Claim being made against any proposed Insured, or do they know of specific facts or circumstances which may give or have given rise to a Claim?

Yes

No

If Yes, please give full particulars (send separate correspondence if necessary):

General Liability Section - OPTIONAL

1. Have any General Liability claims or suits been made during the past five years against the Applicant or is the Applicant aware of any circumstance, act, error, omission or injury or occurrence that could result in any claim being made against the Applicant?

Yes

No

If Yes, please give full particulars (send separate correspondence if necessary):

I/We am currently a paid up member of association: (Association Membership is not required in order to obtain coverage)

It is understood that the insurance applied for will issue on the 1st day of the month following receipt of the premium and the acceptance of the application by the Underwriters. I/We hereby declare, based upon my/our knowledge and upon reasonable investigation, the above statements are true and that I/we have not suppressed or misstated any material facts and this application shall be the basis of the contract with Underwriters.

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance 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.

Pursuant to the provisions of the Electronic Signatures in Global and National Commerce Act (E-SIGN, 2000) execution of the application form by means of typing ones name, title and date below carries the same weight and legal effect as traditional paper documents and handwritten signatures. Further, as a principal of Applicant, I confirm that I have authority to execute this application on behalf of Applicant.

/s/ *

Name of person completing application

Signer's Title