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► PPLICATIoN <br />Northland LAWYERS PROFESSIONAL LIABILITY INSURANCE-Z <br />koamnceComp es (CLAIMS -MADE AND PIEPORTED BASIS) <br />Notice, This is an application for s claims-rnad.e policy. It 2 P011cy is !SSUed, i is application will becom-s - , <br />attached to and form a part of the Policy. Review the policy carofully and discuss the co-verage with y aLer a er€t err <br />Necker. <br />Before completing this application, read the following instructlons and the declaration statemer;t on page � <br />1. All questions must be anstviered. If "nom�" or "not applicable" is time answer, therm such answer must b <br />2. Where space is inaufficient, attach additional sheets. <br />M. Whare directed, complete the -supplemental applications. <br />4. 'rho application, qnd suppl'emenis whom appiioa>ble, must be signed by a partner, officer or director of the <br />Enolo*;e a copy of your current letterhead, <br />BUSINESS INFORMATION <br />1. Named Insured(s) (If partnership, association,, corporation or sale practitioner, provide fall name of firrn): <br />Date Eqtablishe'd: <br />7. Principal Address. y %h] Dr` 5 ' 4- DD <br />3. Branch Office(s) Address: 5 &!� Q A d ICAn <br />4. <br />Exist the names of all Predecessor Firms during the past 1 Q years, (include firms acquired ar MLt ,rq,�d into the fain) <br />Pmdecessor Firms are those where the firm is majority successor in interest of financial assets anri 1i2hHffii4­,- <br />tklarne of Firm <br />Year <br />Established <br /># of Partners, <br />Officers, Directors <br />-# of employed <br />Lawyers <br />5, business type; Sole Practitioner f Partnership Q Professional Corporation U Professional Association <br />Q Other <br />6. In tine last 'five years, have you: <br />a. Changed name of firm? <br />b. Merged with any firm? <br />c. Acquired control of any firm? <br />d. 'Otherwise changed your business structure or location? <br />If yes, provide details on a separate attachment <br />Yes No <br />U 10 <br />SMO-E4 (9198) <br />Wage : of 7 <br />