AUDIT INSURANCE FEATURESx

Physicians Regulatory Insurance Program Application Neil M. PeimanAgency Compliant Services & Solutions Inc ContactAddress P.O. Box 214751FL.City South Daytona State Zip Code 32121 321-821-1812 auditinsurance@compliantusa.comBusiness Phone Fax E-mail Address877-322-6203 X102The insurance for which you are applying is a claims-made and reported form of coverage. Only claims first made and reported to theUnderwriters on or after the effective date but before the end of the Policy Period, or any applicable extended reporting period, will becovered, subject to any retroactive date. This Application will give the Underwriters an understanding of your billing practices. The completion of this application does not bind coverage. Allquestions must be answered completely. If a question is not applicable, answer by stating “Not Applicable” or “NA”. If the answer to a question isnone, answer by indicating “None” or “O”. If more space is needed to answer a question, attach a separate piece of paper and identify the questionto which it pertains. The Physician/Practitioner Warranty Statement (Section V) must be completed and signed by an officer of the practice.I. GENERAL INFORMATION Applicant’s Name (If entity please state)AddressCity State Zip CodeBusiness Phone FaxRequested Effective Date Requested Retroactive Period 1 Year 2Years 3Years 4Years 5Years 6Years Name of entity as it is Type of entity (i.e. P.A., to appear on policy documents P.C., LLP, ...