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c. Number of suits for collection of fees filed by the frrn during the past two years: -- Iv,0Yj4, . _. <br />d. Percentage of the firm's billings that are more than 90 days overdue: C,5 jh. am 5�v <br />e. Yttith respect to the total of all custodW accounts other than retainer fees, what is theme dofiar amount and <br />maximum dollar 4mount held or maintained on behalf of the firm's client ? <br />Average IQ/ A _ Maximum $ <br />DESIRED TERMS AND CONDITION$ .-- <br />Limit of liability desired.- $ <br />DetiuctEble desired.- $ -- � y ... Proposed troaekive date: <br />a v+1 <br />Proposed effective date: _ !A 3 � <br />(The policy teem will be one year unless otharwi, e specfed,) <br />NO FACT, CIRCUMSTANCE, ACT OR OMISSION WHICH COULD REASONABLY BE EXPECTED TO RESULT iN A <br />'CLAIM" OR ACTION AGAINST WHICH INDEMNIFICATION WOULD BE AFFORDED BY THE PROPOSED <br />INSURANCE IS NOW KNOWN BY ANY PERSON OR ENTITY APPLYING FOR THIS INSURANCE OTHER TI-1AN THA, <br />WHICH IS €DISCLOSED IN THIS APPLICATION. IT IS AGREED BY ALL CONCERNED, WITHOUT PREJUDICE TO <br />ANY OTHER RIGHTS ANO REMEDIES OF THE COMPANY, THAT IF ANY PERSON OR ENTITY APPLYING FOR THIS <br />INSURANOF HAS ANY KNOWLEDGE OF ANY SUCH FACT, CIRCUMSTANCE OR SITUATION, ANY'CLAIM" <br />SUBSEQUENTLY EMANATING THEREFROM SHALL BE EXCLUDED FROM COVERAGE UNDER THIS PROPOSED <br />INSURANCE AS TO ALL, INSURED PERSONS. <br />THE UNDERSIGNED AUTHORIZED AGENT OF THE PERSONS AND ENTITY(IFS) PROPOSED FOR THIS <br />INSURANCE FOR THE PURPOSE OF THIS APPLICATION DECLARES THAT THE APPLICANT HAS RECEIVED AND <br />READ A SPECIMEN FORM OF THE .INSURANCE CONTRACT FOR WHICH APPLICATION IS MADE, AND THAT <br />EACH OF THE INDIVIDUALS AND ENTITIES PROPOSED FOR COVERAGE UNDER THE INSURANCE CONTRACT <br />- ,R WHICH APPLICATION IS MADE. <br />(1) HAS NO UNANSWERF-D QUESTIONS CONCERNIWO THE INSURANCE CONTRACT; <br />(2) HAS NO EXPECTATIONS THAT THE POLICY PROVIDES COVERAGE BEYOND THAT SET FORTH IN THE <br />LANGUAGE OF THE POLICY ITSELF; <br />(3) UNDERSTANDS THAT THE POLICY FOR WHICH APPI<ICATION IS MADE, SUBJECT TO ITS TERMS, Af'PHES <br />ONLY TO ANY "CLAIM' FIRST MADE ARID REPORTED AGAINST THE INSURED PERSONS DURING THE^ <br />POLICY PERIOD AND SUBJECT TO THE TERM,$ AND -CONDITIONS OF THIS APPLICATION AND THE POL1cY <br />FRAUD STATEMENT <br />I DECLARE THATTHE STATEMENTS MADE IN TH;S APPLICATION ARE COMPLETE AND TRUE. <br />Any person, who, with the intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an <br />application or files a claim containing a false or deceptive statement may be guilty of insurance fraud and subject to fines <br />and/or imprisonment. Any changes in your operation must be reported to your agent. <br />WARRANTY AND SIGNATURE <br />By signing this application, the applicant warrants that -the statements made in this application or attached to this <br />application are complete and true. If a peficy is Essued, this application will be attached to and becorne a part of the policy. <br />All statements matte can this application or attached to this application are the basis of the poiicy and are deerned material <br />to the acceptance of the risk or the hazard assumed by us, If issued, the policy will be in raflance upon the truth of such <br />statements and attachments. Jf this application or its attachments colitain any misrepresentations which matadally affect <br />either the acceptance of the risk or the hazard assumed by as, the policy will be void and of no effect. <br />a1M30-Eo (0m) Page €i of 7 <br />