Insurance Survey

Preface: Professional liability insurance has become more expensive and harder to obtain from high rated
insurance companies. We have begun discussions with Americana Program Underwriters, a member company
of American Wholesales Insurance Group www.amwins.com, about developing an insurance program for our
members.

Please complete the following questions for us. All information will be kept confidential.

Thank you, for your usual cooperation.

1. Do you currently buy Professional Liability Insurance?
   Yes No
   (If No, please go to "Comments" and tell us why)
   
2. What Limit of Liability do you have?
   $100,000/$300,000 $250,000/$500,000 $500,000/$1,000,000 $1,000,000 or more
   
3. 1. Approximately how much is your current annual premium for Professional Liability?
      $
   2. Approximately how much was your premium last year for Professional Liability?
      $
   3. Approximately how much was your premium 3 years ago for Professional Liability?
      $
      
4. Your business is located in which state?
   
   
5. Does your carrier offer you an interest free installment payment plan?
   Yes No
   
6. Have you ever been sued, claiming that you are liable for an error or omission in providing professional
   services?
   Yes No
   
   [If yes, please indicate the amount either paid by your insurance carrier or the amount they have in reserve]
   Claim #1 - $ Paid Reserved - Year:
   Claim #3 - $ Paid Reserved - Year:
   Claim #3 - $ Paid Reserved - Year:
   
7. What is the name of your insurance company?
   
8. Are you a member of NACHI?
   Yes No
   

Comments (Please share any facts or issues you have about Professional Liability Insurance or other insurance
issue which concern you)