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AM <br />H I SCOX <br />Hiscox Insurance Company Inc. <br />Your Business does not conduct any of the following activities: I have read and agree <br />-Automotive repair or sales <br />- Food service/restaurant operations <br />- Medical services <br />- Retail operations <br />Note: This does not include the activities of your clients in any of these industries <br />Based upon your knowledge and the knowledge of your business's current and past I have read and agree <br />partners, officers, directors and employees, during the last five years a third party <br />has never made a claim against your business and you do not know of any reason <br />why someone may make a claim. <br />The limits of liability represent the total amount available to pay judgments and settlements for any <br />not liable for any amounts that exceed these limits. <br />If coverage is provided, it shall apply only to occurrences that take place during the policy period. <br />We are <br />Judgments, settlements and claims expenses incurred are subject to a deductible amount. The deductible is the <br />amount you must pay before we will make any payments under the policy. Some coverage may not be subject to a <br />deductible, in which case you are not required to make payments before any payments are made under the policy. <br />Please consult the policy language for details. <br />If you have knowledge of any circumstance that may lead to a loss or a claim being made against you, <br />coverage will be excluded if such loss occurs or claim is made. <br />Occurrences that took place prior to the inception of the policy are excluded. <br />Fraud Warning <br />It is a crime to knowingly and intentionally attempt to defraud an insurance company by providing false or <br />misleading information or concealing material information during the application process or when filing a claim. <br />Such conduct could result in your policy being voided and subject you to criminal and civil penalties. <br />Optional Terrorism coverage <br />You have elected to purchase optional terrorism coverage. Yes <br />Optional Waiver of Subrogation <br />You have declined to purchase a Waiver of Subrogation. Yes <br />You have confirmed that you agree with the General Statements provided. Yes <br />I agree to accept delivery of my insurance policy via email to the address provided. Yes <br />I have read the information above and confirm it is all correct. I understand that by Yes <br />checking this box I am agreeing to enter into a binding agreement with Hiscox <br />Insurance. <br />Optional Business Personal Property Coverage <br />You have declined to purchase optional business personal property and equipment Yes <br />coverage: <br />© Hiscox Inc. 2010 Page 3 <br />