Errors & Omissions Insurance For Private Issuers In Alberta

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NOTE: If the spaced provided to answer any of the questions on this application are insufficient to fully answer the question, please use the remarks section at the end of the form. If it is a continuation from a particular question, please be sure to indicate which question.

Name of Applicant

Address

Phone Number

Fax Number

Location of Branch Offices

Complete description of the Applicant's activities:

Indicate number of years Applicant has provided such services:

Total Number of Issuer Employees:

Total Number of Clerical Employees:

Please indicate the Applicant's gross annual fees and number of transactions for the past year: Gross Annual Fees:

Number of Transactions:

Please indicate the Applicant's gross annual fees and number of transactions anticipated for the upcoming year: Gross Annual Fees:

Number of Transactions:

Loss Experience In the past, has the Applicant or any of his/her employees ever been the recipient of any allegations of professional negligence either in writing or verbally? Yes No

If 'Yes', please provide details:

Is the Applicant or any of his/her employees aware of any facts, circumstances or situations which may reasonably give rise to a claim, other than as advised above? Yes No

If 'Yes', please provide details:

REMARKS (optional - or use to complete questions above)