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11AM <br />HISCOX <br />Hiscox Insurance Company Inc. <br />Including yourself, how many full-time, part-time, and temporary employees does 1-4 <br />your business have? (Do not include subcontractors.) <br />Is your business operated out of your home? No��� <br />Other than the business address provided above, how many additional locations 0 <br />does your business own or rent? <br />Address: NotApplicable <br />Do you or your business supply, manufacture, or distribute any tangible goods or No <br />products? <br />Note: Brochures, documents and reports are not considered as tangible goods. <br />__ w <br />Does your business perform any design, construction, installation, removal or ,- No <br />physical repair of any property or tangible good? <br />Does your business provide any of the following services? No <br />• Aerospace consulting or advice <br />• Architecture or engineering advice <br />• Construction management or advice <br />• Environmental consulting or advice <br />• General contracting <br />• Land acquisition <br />• Law enforcement training <br />• Medical advice <br />• Mining consulting or advice <br />• Oil, gas, or petroleum consulting or advice <br />• Safety consulting or advice <br />• Sales representative. <br />For the next 12 months, what is your estimated payroll expense for yourself, your $ 5,000 <br />full-time, part-time, and temporary employees? (Do not include subcontractors.) <br />As the individual completing this transaction, you are authorized to purchase and I have read and agree <br />bind this insurance on behalf of the entity applying for coverage. <br />Your business is not controlled or owned by any other firm, corporation, or entity.. I have read and agree <br />For the entire period of time that you have owned and controlled the business, You I have read and agree <br />have not sold, purchased or acquired, discontinued, merged into or consolidated <br />with another business. <br />Your business has never had any commercial insurance cancelled or rescinded. I have read and agree <br />© Hiscox Inc. 2010 Page 2 <br />