2007-2008 IEEE Multiplan Brochure

13. A. List Engineers’ Professional Liability Insurance carried by you or your firm for the past two years. Inception Date Mo-Day-Yr Expiration Date Mo-Day-Yr Insurance Company Annual Premium Limit of Liability If none, state “none.” Deductible B. Please provide your policy’s current retroactive date: If none, state “none.” C. Please provide the date that you/your firm first purchased claims-made professional liability coverage and have since continuously maintained the coverage: / / . If not applicable, please check: J N/A (mm) (dd) (yy) D. If currently insured, please submit a copy of your current declarations page with your completed application. 14. A. Has any application or policy of yours or your firm’s for professional liability insurance ever been YES NO declined, canceled or refused renewal? If “Yes,” please provide details on a separate sheet of paper J J B. Have you or members of your firm had your license revoked or received suspension or other disciplinary action from a governmental or judicial body or professional society during the past five years? J J If “Yes,” please provide details on a separate sheet of paper, including a copy of the ruling. C. Have any claims been made or legal actions been brought against you or your firm in the past five years?* J J D. After inquiry of firm members, is anyone aware of any circumstances that may result in a claim being made against the firm or any individual?* J J *If “Yes,” please complete the Claim Information Supplement form enclosed for each claim and/or circumstance. 15. Please provide your website address, a copy of your current résumé, letterhead, and typical advertising/sales/marketing brochures used by you or your firm. NOTICE TO APPLICANT: I/We hereby declare that the above statements and particulars are true to the best of my/our knowledge and that I/we have not suppressed or misstated any material facts and I/we agree that this application shall be the basis of the issuance of insurance coverage and shall be attached thereto. I/We hereby authorize the release of claim information from any prior insurer to the Underwriters. I understand and accept that the policy applied for provides coverage on a “claims-made” basis for ONLY THOSE CLAIMS THAT ARE FIRST MADE AND REPORTED TO THE COMPANY DURING THE POLICY PERIOD FOR ACTS THAT OCCUR AFTER THE POLICY’S RETROACTIVE DATE AND PRIOR TO THE EXPIRATION DATE OF THE POLICY. Signature of Owner, Officer or Partner: (TITLE) X Date X Signing this form and tendering premium does not bind the applicant or the Underwriters to complete the insurance. Application must be currently signed and dated to be considered for quotation. Sign, date and mail your application to: Administrator, IEEE Group Insurance Program, P.O. Box 9153, Des Moines, IA 50306-9153; or fax your application to 515-365-3043 Underwritten by: Certain Underwriters at Lloyd’s of London Administered by: QUESTIONS? CALL TOLL FREE 1-800-375-0775 AIF 2384 A (8/07) NOTICE: Failure to report any: 1) claim made against you during your current policy term, or 2) facts, circumstances or events that may give rise to a claim to your current insurance company BEFORE policy expiration may create a lack of coverage.

Table of Contents Feed for the Digital Edition of 2007-2008 IEEE Multiplan Brochure

Group Term Life Insurance Plan Group 10-Year Level Term Life Insurance Plan Group 20-Year Term Life Insurance Plan Group Disability Income Insurance Plan Professional Liability Insurance Plan Long-Term Care Plan Additional Plans & Information

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