A&E PRACTICE BUSINESS OFFICE PACKAGE APPLICATION

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Gerard Park
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1 A&E PRACTICE BUSINESS OFFICE PACKAGE APPLICATION Section 1. General Information 1. a. Applicant: b. Federal ID #: c. Primary Mailing Address: Address City State Zip d. Pho #: e. # Offices: # f. Founded: g. s at This Location: # h. Type of Entity: Corp, Partnership, Sole Proprietor 2. a. Primary Contact Person: b. Accounting Contact Person: c. Claim Contact Person: 3. Is the Applicant: a. Involved in more than design services, such as Construction Management or Design/Build services? Yes*, No b. A subsidiary entity or have any subsidiary entity? Yes*, No c. An owner/operator of another business? Yes*, No d. Involved in a joint venture in past 5 years? Yes*, No e. Operations sold/acquired/ discontinued in past 5 years? Yes*, No * If yes, provide details: 4. Is A&E Professional Liability Coverage currently in force? Yes*, No * If yes, list insurance co., limit & effective date: Section 2. Business Office Package Coverage Requirements 1. Commercial General $1,000,000 each occurrence/$2,000,000 aggregate limit Liability Limit Desired: $2,000,000 each occurrence/$4,000,000 aggregate limit (i.e., Covers bodily injury and property damage claims that does not arise from professional service related activities.) 2. Umbrella Liability Limit Desired: NA, $1,000,000 Other: $ 3. Damages to Premises Rented to You Applicant Limit Desired: NA, $300,000, $500,000 $750,000, or $1,000,000 (i.e., Covers property damage liability to space that is rented or leased by the Applicant.) 4. a. Past Year Annual Gross Revenue: $ b. # of Owners & Professional Employees: # 5. Are Employee Benefit Plans provided? Yes*, No * If yes, list plan name(s): (i.e., Covers liability of an employer for an error or omission in the administration of an employee benefit program) 6. Are Employee Retirement 401K or Profit Sharing Plans provided? Yes*, No * If yes, list plan name(s) and dollar value: (i.e., Protects against theft of funds from retirement plans, which is required under ERISA) 7. Employment Practice Limit Desired: NA, $25,000, $100,000, or $250,000 (i.e., Protects against employment claims, such as wrongful termination/discrimination/sexual harassment allegations.) Page 1 of 5

Involved in more than design services, such as Construction Management or Design/Build services? Yes*, No b. A subsidiary entity or have any subsidiary entity? Yes*, No c.

2 Section 3. Business Office Package Property Coverage 1. Location #1: Primary Office Location Information a. Check Applicable Boxes: Home*, Owner/Lessor, Owner/Occupant, Tenant * Provide insurance co. name/policy expiration date: b. Location #1 Address: Address City State Zip 2. Construction Type: Frame, Joisted Masonry, Masonry, Non-Combustible, Non-Combustible, or Fire Resistive Frame: Exterior walls of wood, brick veneer, stone veneer, wood ironclad, stucco on wood. Joisted Masonry: Exterior walls of masonry material (adobe, brick, concrete, gypsum block, hollow concrete block, stone, tile, or similar materials), with combustible floor and roof. Masonry, Non-Combustible: Exterior walls of masonry material (adobe, brick, concrete, gypsum block, hollow concrete block, stone, tile, or similar materials), with floor and roof of metal or other noncombustible materials. Non-Combustible: Exterior walls, floor, and supports made of metal, asbestos, gypsum, or other noncombustible materials. Fire Resistive: Exterior walls, floors, and roof of masonry or fire-resistive material with a fire-resistance rating of at least 2 hours. 3. a. Year Building Constructed*? b. # Stories: * If over 20 years old: (i) Year Roof Last Updated: 4. Does Building have a: (ii) Year Electrical Last Updated: (iii) Year Heating Last Updated: (iv) Year Plumbing Last Updated: a. Smoke Detector Yes, No b. Sprinkler System (for 100% of property) Yes*, No * If yes, list Earthquake Sprinkler Leakage Property limit required: $ (i.e., Limit should equal total of Property Limits listed in Q 6c through h (i & ii) on page 3) c. Central Station Burglar Alarm Yes*, No d. Central Station Fire Alarm Yes*, No * List name of monitoring firm: 5. Basic Information about This Location: a. Applicant occupied square footage # sq. ft. b. Total property square footage # sq. ft. c. Estimated unoccupied square footage % d. Single occupancy applies? Yes, No* * If no, check as many boxes that applies: (i) Other building occupants: Office, Service, Retail, Residential, Wholesale, Industrial, Restaurant, or Other: (ii) Occupancy of adjacent firms: Office, Service, Retail, Residential, Wholesale, Industrial, Restaurant, or Other: Page 2 of 5

Construction Type: Frame, Joisted Masonry, Masonry, Non-Combustible, Non-Combustible, or Fire Resistive Frame: Exterior walls of wood, brick veneer, stone veneer, wood ironclad, stucco on wood.

3 e. Air conditioning: Yes, No f. Ongoing building maintenance or inspections: Yes, No g. Building undergoing renovation: Yes, No h. Two fire hydrants within 500 feet of premises: Yes, No 6. Property Coverage Limits Desired: a. Building Limit (i.e. if owned by Applicant): NA $ b. Property Deductible Desired: $500, $1,000, $2,500, Other: $ c. Business Personal Property Limit: $ (i.e., Includes replacement cost of business personal property, property of others/leased property in the applicant s care/custody/control. Examples include furniture, equipment, and material used to operate your business.) d. Tenant Improvements & Betterments Limit: NA $ (i.e., Includes replacement cost of office fixtures that the applicant permanently installed and was not provided by the landlord. Examples include interior walls, cubicles, shelving/cabinetry, kitchens, internal wiring or plumbing.) e. Computer & Media Limit: $ (i.e., Includes replacement cost of computers, related component hardware/software, and peripheral devices such as modems, printers, and scanners.) f. Electronic Data Processing Data & Media Limit: $ (i.e., Estimated cost to research/replace/restore lost electronic data stored on computers and media and the replacement of blank media.) g. Valuable Paper/Records Limit: (i) <$100K, (ii) List if Over >$100K: $ (i.e., Cost to research/replace/restore lost information for which duplicates do not exist. Examples include inscribed/ printed/written documents, and records/manuscripts including specifications, drawings, films, card index systems, maps, abstracts, deeds, and books.) h. (i) Fine Arts Limit: NA $ (ii) Architectural Models Limit: NA $ (iii) Contractor s Equipment Limit NA, List Attached $ (i.e., Special coverage for specialized equipment and valuable tools where such equipment is stored, when in transit and while used at a particular job site where the value exceeds the actual cash value of $1,000 any one tool or $2,500 for any one toolbox or item of equipment) Section 4. Prior Business Office Package Coverage Information 1. Has the Applicant purchased a Business Office Package policy in the past three (3) years? Yes*, No * If yes, provide: (i) Prior insurance company information: Insurance Company Expiration Date Premium (ii) Past three (3) year insurance co. loss history report: NA, Attached, or Requested Page 3 of 5

Examples include furniture, equipment, and material used to operate your business.) d. Tenant Improvements & Betterments Limit: NA $ (i.e., Includes replacement cost of office fixtures that the applicant permanently installed and was not provided by the landlord.

4 2. Has any Business Office Package policy been declined, cancelled or non-renewed in the past three (3) years? Yes*, No * If yes, provide details: Section 5. Non-Owned/Hired Automobile Coverage 1. Does the Applicant have a Business Automobile Liability policy in force? Yes*, No * If yes, proceed to Section 6 and contact PPIB for Business Automobile Liability application. 2. a. Do employees/owners use their vehicles on company business? Yes*, No * If yes, provide the following information that best describes typical weekly usage: (i) < Once, Once, > Once (ii) # that use their vehicles: # b. Are employees/owners required to carry their own auto liability insurance? Yes*, No * If yes, list minimum liability limits required and verified: $ 3. Does the Applicant lease, hire or rent any vehicles for company business? Yes*, No * If yes, provide the estimated annual cost of such vehicles: $ Section 6. Mortgagee, Loss Payee & Additional Insured Information 1. Provide Mortgagee and Loss Payee (i.e. Leased Property) information: NA Full Name Address City, State & Zip Reference # Mortgagee/ Loss Payee Mortgagee/ Loss Payee 2. Provide list of Additional Insureds (i.e. when required by a contract): NA, or Attached Section 7. Miscellaneous Questions Provide additional information by replying in Section 9 of this application ONLY IF YES applies to any of these questions: NA, or Information Attached 1. Exposure to flammables, explosives, or chemicals? 2. Exposure to radioactive or nuclear material? 3. Operations include excavation, tunneling, underground work or earth moving? 4. Past, present, or discontinued operations involving storing, treating, discharging, applying, disposing, or transporting of hazardous material (i.e. landfill, wastes, fuel tanks, etc.) 5. Are medical facilities provided or medical professionals employed or contracted? 6. Equipment or machinery loaned or rented to others? 7. Aircraft/watercraft docks, floats owned, hired or leased? 8. Lease employees to or from other employers? 9. Labor interchange with any other business or subsidiary? 10. Office location is within 1,000 feet of a shoreline? Page 4 of 5

Yes*, No * If yes, provide the following information that best describes typical weekly usage: (i) < Once, Once, > Once (ii) # that use their vehicles: # b.

5 Section 8. Signatures PPIB BUSINESS OFFICE PACKAGE APPLICATION MUST BE SIGNED AND DATED BY OWNER, PARTNER OR SENIOR OFFICER. (Applicant Signature) (Month/Day/Year) (Print or Type Name & Title) Section 9. Additional Information: Use As Needed Concerning Replies to Application Questions Page 5 of 5

APPLICATION FOR OFFICE PROPERTY & GENERAL LIABILITY INSURANCE. Name of Organization: Physical Address: Mailing Address: City: State: County: Zip:

APPLICATION FOR OFFICE PROPERTY & GENERAL LIABILITY INSURANCE GENERAL INFORMATION Name of Organization: Physical Address: Mailing Address: City: State: County: Zip: Phone: ( ) Fax: ( ) Contact: Email Address: