ARBITRATORS, HEARING OFFICERS AND MEDIATORS PROFESSIONAL LIABILITY INSURANCE

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

3. If Assured is not an individual, specify whether:
 
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):
 NameArbitrator, Hearing Officer or MediatorPT or FT (PT is 20 hrs. a week or less)10 Cases or Less Annually (Y/N)
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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):
 CategoryNumber of Cases
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10. State whether the numbers specified in your answer to Questions 8 & 9 are estimated figures:
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?
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?
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?
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?
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 at Lloyd's, London.

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.