Specialty Global Insurance Services8500 Shawnee Mission Parkway, L2

a division of MPP Company, Inc.Shawnee Mission, KS 66202

Telephone: / (913) 564-0777
Facsimile: / (913) 564-0603

specialtyglobal.com

Applicant Name:

“Applicant” refers individually and collectively to the corporation(s), partnership(s) or sole proprietorship(s) for which coverage is desired, as well as each person who is an officer, director, owner, partner or employee of those organizations.

This statement must be signed and dated by anauthorized partner, officer, or other principal of the Applicant and on behalf of all Applicants as described above.

The undersigned warrants,that to the best of their knowledge, and after reasonable investigation, between and the date this statement is signed:

Neither Applicant nor any of the Applicant’s predecessors in business, affiliates nor any of the Applicant’s past or present partners, owners, officers, sales persons or employees have been or are currently being investigated and/or cited by any regulatory agency or other governmental entity or certifying body;

No Claims, suits or proceedings have been brought against the Applicant or the Applicant’s predecessors in business, affiliates or any of Applicant’s past or present partners, owners, officers, sales persons or employees;

Applicant is NOT aware of any actual or alleged fact, circumstance, situation, error or omission, which may reasonably be expected to result in a Claim being made against Applicant.

Please provide complete details if there are any variations to the above statements:

Please note:

The policy the Applicant is applying for, if issued, will not insure any Claims that can reasonably be expected to arise from any actual or alleged fact, circumstance, situation, error or omission known to any Applicant before the Inception Date of the policy;

The policy the Applicant is applying for, if issued, will not insure any Claims made against the Applicant prior to the Inception Date of the policy or any subsequent claims, suits or proceedings arising therefrom.

Signature / Title
Date
SG-CF-102 (12-06) / Copyright Specialty Global Insurance Services 2006