SERFF Tracking #: MRTN State Tracking #: Company Tracking #: CL DC

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1 Product Name: Cover Pro Miscellaneous Professional Liability Short Renewal Application Filing at a Glance Company: Product Name: State: TOI: Sub-TOI: Filing Type: Philadelphia Indemnity Insurance Company Cover Pro Miscellaneous Professional Liability Short Renewal Application District of Columbia 17.0 Other Liability-Occ/Claims Made Professional Errors & Omissions Liability Date Submitted: 04/05/2015 SERFF Tr Num: SERFF Status: State Tr Num: State Status: Co Tr Num: Effective Date Requested (New): Effective Date Requested (Renewal): Author(s): Reviewer(s): MRTN Closed-APPROVED CL DC On Approval On Approval Barb Blackowicz, Brian Thomas Angela King (primary) Disposition Date: 04/27/2015 Disposition Status: APPROVED Effective Date (New): 04/27/2015 Effective Date (Renewal): 04/27/2015

2 Product Name: Cover Pro Miscellaneous Professional Liability Short Renewal Application General Information Project Name: Cover Pro Miscellaneous Professional Liability Short Renewal Application Project Number: CL DC Reference Organization: Reference Title: Filing Status Changed: 04/27/2015 State Status Changed: Created By: Barb Blackowicz Corresponding Filing Tracking Number: Status of Filing in Domicile: Domicile Status Comments: Reference Number: Advisory Org. Circular: Deemer Date: Submitted By: Barb Blackowicz Filing Description: Attached for your review is a Filing Authorization Letter authorizing Martin & Company to submit this filing on behalf of Philadelphia Indemnity Insurance Company (hereinafter referred to as the company). Please direct all correspondence regarding this filing to Martin & Company. The company is filing for your review and approval, the new Cover Pro Miscellaneous Professional Liability Short Renewal Application for use with their previously submitted Cover Pro Coverage and corresponding endorsements. The following renewal application included: Cover Pro Miscellaneous Professional Liability Short Renewal Application There are no rates associated with this filing. The company would like to implement these forms immediately upon approval by the Department. If you have any questions or require additional information, please do not hesitate to contact us. Company and Contact Filing Contact Information Barbara Blackowicz, Compliance Analyst P.O. Box 70 Edgemont, PA [email protected] [Phone] [FAX] Filing Company Information (This filing was made by a third party - martinandcompany) Philadelphia Indemnity Insurance Company One Bala Plaza Suite 100 Bala Cynwyd, PA (610) ext. [Phone] CoCode: Group Code: 3098 Group Name: Philadelphia Insurance Co FEIN Number: State of Domicile: Pennsylvania Company Type: P&C State ID Number:

3 Product Name: Cover Pro Miscellaneous Professional Liability Short Renewal Application Filing Fees Fee Required? Retaliatory? Fee Explanation: No No

4 Product Name: Cover Pro Miscellaneous Professional Liability Short Renewal Application Correspondence Summary Dispositions Status Created By Created On Date Submitted APPROVED Angela King 04/27/ /27/2015

5 Product Name: Cover Pro Miscellaneous Professional Liability Short Renewal Application Disposition Disposition Date: 04/27/2015 Effective Date (New): 04/27/2015 Effective Date (Renewal): 04/27/2015 Status: APPROVED Comment: Rate data does NOT apply to filing. Schedule Schedule Item Schedule Item Status Public Access Supporting Document Readability Certificate APPROVED No Supporting Document Consulting Authorization APPROVED No Supporting Document Copy of Trust Agreement APPROVED No Supporting Document Expedited SERFF Filing Transmittal APPROVED No Supporting Document Explanatory Memorandum APPROVED No Cover Pro Short Application Express Renewal Questionaire APPROVED Yes

6 Product Name: Cover Pro Miscellaneous Professional Liability Short Renewal Application Schedule Item Schedule Item No. Status 1 APPROVED 04/27/2015 Name Cover Pro Short Application Express Renewal Questionaire Number PI-PLSP-3 RENWL SHORT APP Edition Action Specific Readability Date Type Action Data Score Attachments 1/15 ABE New Cover Pro short Application Express Renewal Questionnaire MPL 1 15.pdf Type Legend: ABE Application/Binder/Enrollment ADV Advertising BND Bond CER Certificate CNR Canc/NonRen Notice DEC Declarations/Schedule DSC Disclosure/Notice END Endorsement/Amendment/Conditions ERS Election/Rejection/Supplemental Applications OTH Other

7 EXPRESS RENEWAL QUESTIONNAIRE MISCELLANEOUS PROFESSIONAL LIABILITY Applicant s Name: Applicant s Address: Policy Number: Risk Management Contact: Cell Phone: SECTION I GENERAL INFORMATION 1. Has Applicant s company offered any new services since the last renewal? (If yes, attach details) Yes No 2. Have any services changed over 25% of revenue? (If yes, attach details) Yes No 3. During the last 12 months, has the Applicant s Firm s company name changed or has any other business been acquired, merged into, or consolidated with Applicant s Firm? ( If yes, provide complete explanation) Yes No 4. Date of Firm s current Fiscal period: From: To: Past Fiscal Year Current Fiscal Year Next Year Estimated Estimated Total Annual Gross Revenue $ $ $ 5. Was more than 50% of Applicant s total gross annual revenue derived from a single client or contract during the past year? If yes, provide the following: Yes No a. Client s Name: b. Services Rendered: c. How long is the relationship expected to continue: 6. Does the Applicant secure a written contract or agreement for every project? Yes No If no, provide the percentage of gross annual revenue where a written contact is secured. % Note that any significant exposure changes from previously completed applications may require that the Insured complete a PHLY renewal application. Please note that we may at our option send a confirmation of this information to the insured either prior to the effective date of this renewal or at the end of this renewals policy term. PI-PLSP-3 RNWL SHORT APP (1/15)

8 FRAUD NOTICE STATEMENTS 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 AND SUBJECTS THAT PERSON TO CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A FRAUDULENT INSURANCE ACT WHICH MAY BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS ($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION). (NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN, NM, OK, RI, TN, VA, VT, WA AND WV). APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN PRISON. APPLICABLE IN COLORADO: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES, DENIAL OF INSURANCE AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AGENCIES. APPLICABLE IN FLORIDA AND OKLAHOMA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY (IN FL, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE). APPLICABLE IN KANSAS: ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE PRESENTED OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER OR ANY AGENT THEREOF, ANY WRITTEN STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY FOR PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY FOR COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT. APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES OR A DENIAL OF INSURANCE BENEFITS. The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge and belief and after reasonable inquiry, that the statements set forth in this Application (and any attachments submitted with this Application) are true and complete and may be relied upon by Company * in quoting and issuing the policy. If any of the information in this Application changes prior to the effective date of the policy, the Applicant will notify the Company of such changes and the Company may modify or withdraw the quote or binder. The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy. *Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company. COMPLETED BY (NAME / TITLE) Please type or print SIGNATURE (Insured or Producer) DATE PRODUCED BY: (SECTION TO BE COMPLETED BY PRODUCER/BROKER) PRODUCER AGENCY PRODUCER LICENSE NUMBER AGENCY TAXPAYER ID OR SS NUMBER ADDRESS (STREET, CITY, STATE, ZIP) PI-PLSP-3 RNWL SHORT APP (1/15)