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� <br />Business Risk Partners, Alternative oisnvle Resolution Professionals Liability Application, 11 /04 <br />GO- <br />B u S I S s R I S K 1-17»mIRTNi E. I q <br />p^^.�'v*xo'za� <br />ALTERNATIVE DISPUTE RESOLUTION PROFESSIONALS LIABILITY APPLICATION <br />Please complete the application by either entering m <br />application and entering the Information by hand. You will need Adobe Acrobat Reader Version 4.0 (at mInImurn.) If you are <br />using version 3.0, you can upgrade It for free at %wAy.adobe.com. Fox, mail, or email the completed application to Business <br />Risk Partners at the address noted above. <br />Name ofApplicant: AR 4-S,4 <br />1. <br />— E-mail Address <br />mebo��fddraom: ' �— <br />3. Applicant is: El Firm <br />4. Please indicate the total number uffuU and part-time Arbitrators: <br />(This Includes Private Judges u Judge Pro Terns) <br />u. Please Indicate the total number of full and part-time Mediators: <br />(This Includes Fact Finders, Referees, Special Moslem and Neutral Evaluators) <br />s. Do you spend more than 2V hours per week providing ADIRservices? El Yes $6 <br />7. Are more than 1V%of your AOR services |n the area mf Family Mediation mr Consumer A0R? _/ ' <br />. <br />[l Yes ��^u <br />8. a. Have any professional liability clalm(s) or suits ever been made against the Applicant, or any <br />'x <br />din~ctur=, officers or L Yes ��� <br />� <br />b. Have they ever been the subject of disciplinary or criminal actions aeo result of their profemaio | <br />activities? []Yoo���" <br />�_� <br />9. Does the Applicant or do any directors, officers or employees have any knowledge of any act, error <br />nniosion, or personal [n]ury, which might reasonably give rise to a claim? []Yes o <br />|, Yes, please d000dbwurnuech detailed inhmnnadon: �—`� <br />It is understood and agreed that if the answer to questions 8,or 9 is "Yes", any such claim or potential <br />Claim is specifically excluded from this proposed coverage. <br />