APPLICATION FOR TRAVEL AGENTS ERRORS & OMISSIONS INSURANCE (CLAIMS MADE POLICY)

NOTE: Completion of this application form does not bind the Insurer to offer the insurance nor does it obligate the Applicant to purchase the insurance. This application is a declaration and shall form part of any policy wich may be issued.



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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.

1. a) Name and Address of Proposer and all Branch Offices:

b) Name(s) of predecessor(s) in business, if any:

c) Email Address

2. Date established as 1(a) or 1(b) above:

3. Full name and experience of: a) Principal and all Partners and Directors Name Age Years in Profession b) All Managers Name Age Years in Profession

4. When did persons stated in Question 3 assume active control of the Agency? a) Principal and all Partners and Directors b) Managers

5. State number of staff: Working Partners or Directors: Typists & Clerical Staff: Managers: Couriers: All Others:

6. Income from the Proposer's Travel Agency Business: a) Gross Receipts Estimated Last Year: Estimated This Year: b) Gross Commission Estimated Last Year: Estimated This Year:

7. a) Does the Applicant arrange tours? Yes No

b) If "Yes", please state percentages of gross receipts derived from (and supply details and brochures if any): 1) Group Tours: 2) Conventions, Seminars, etc.: 3) Student/Incentive Tours: 4) Tours of a hazardous nature: (i.e. mountaineering, safaris, skin diving, or to hostile environments.)

8. Does the Applicant and/or any parent, subsidiary or other related company operate tours? a) Their Own Yes No b) Those of others Yes No

9. Please state percentage of gross income derived from: a) Retail: b) Wholesale:

10. Does the named Applicant act as: a) a Franchisor Yes No b) a Franchisee Yes No If "Yes" to either, please provide full details:

11. Is the named Applicant an active member of: a) American Society of Travel Agents Yes No b) International Air Transport Association Yes No c) Any other pertinent association Yes No

12. Does the named Applicant or any Owner, Partner, or Director thereof engage in any employment or activities other than Travel Agents? Yes No If "Yes", please provide full details:

13. Has the named Applicant been insured previously either under their existing name or that of any predecessor in business? Yes No If "Yes", please provide name of insurer, limit, deductible, date of expiry and whether it was on "Claims Made" or "Occurrence" basis.

14. Has any application for this form of Insurance ever been declined or has any such Insurance ever been cancelled or special terms imposed? Yes No If "Yes", please provide full details:

15. Have any claims been made during the past five years against the Proposer or any of the present Partners or to your knowledge against any past Partner? Yes No If "Yes", please state in each case: - Date claim made - Name of Claimant - Value of claim - If Claim is settled or outstanding - Amount of settlement - Brief details

16. Has the Applicant or any of its past or present Owners, Officers, Partners, Directors or Employees any knowledge or information, after inquiry, or any occurrence whatsoever which might give rise to a claim against you in connection with your profession? Yes No If "Yes", please state in each case: - Date Applicant first became aware of any such alleged negligent act, error, or omission - Name of potential claimant - Estimated value - Brief details

17. Are there any other facts, which, if disclosed to Underwriter, may influence their assessment of this application?

18. a) Amount of Indemnity required: b) Deductible required (Minimum $500):

19. Does the Named Applicant agree that this proposal form is for a Claims made policy? Yes No

REMARKS (optional - or use to complete questions above)