PB Profesional GR LEN The Professional Protector Plan® ea Property Supplement Name: (First/Middle Initial/Last/Designation) Policy Number Desired Effective Date ! ! | PROPERTY INFORMATION (Please comp practice location. Street City County Zip Code which you are located 2. Describe the building in : Construction Floor on of Building No. of Which You Year you occupy Stories | AreLocated | Buill Covet | 2 | 2 [aos] “aco | 400 | 2m | wr | 3. Year building updated (if over 25 years of age) Total Sq. Footage of Building Your Office Year Roof Updated Electric Meets Building Codes Yes No Piumbing is maintained to prevent exposure to leaking or frozen pipes Yes No Building was built for a different occupancy and has been modified Yes No If Yes, please describe: 4. Is your practice location equipped with any of the following systems? a. Sprinkler 8 4 b. Fire alarm . wae 0 0 c. Smoke detectors Lo @ 6 d. Burglar alarm 8 6 a 5. Is your practice located in your residence? if "Yes," does your office have a separate entrance? veves No 6. What is your practice location's distance to the nearest fire station? miles 7. Do you utilize a watchman service? Yes §No 8. Are cash and checks deposited daily?... . 8Yes WNo 9. How do you store your cash on hand, prescription drugs, precious metals? | O4ar‘e 6 Fire Resistive Container 6 Other (describe) a. Amount of cash left on premises overnight . $ _ 5000 b. Value of drugs $ ao c, Value of metals $ SD d. Value of other (describe) $ v7; a 10. How do you store your accounts receivable records? fi 2 11. Do you maintain duplicate accounts receivable records? . aes @No 12. Are accounts receivable duplicates kept off your premises? Pa 8Yes No G-151513-1 (Ed. 05/2006) ! EFTA00311431

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DESCRIPTION OF CONTENTS 13. Are you within 1 mile of an ocean, gulf or river? 14, Are you less than 10 feet above sea level? 15, Total number of operatories: Fully equipped: Partially equipped; 16, Name and address of Loss Payee or Lessor on contents (i.¢., office and dental equipment): Nar L ST Devel LIC bige” "Roel HOM Qexke BB“ Drown Sur” OBE Name treet ity State Zip Code 17. Which coverage do you prefer? §PPP Standard @ PPP Gold (Please contact your agent for information on this valuable coverage) Estimate the total cost to replace Dental Practice Personal Property: PPP Standard A.PracticeContents; LE ee eenee see 1. Furniture and fixtures 2. Operatory equipment 3. Instruments and supplies 4. Improvements and betterments 5. Glass 6. Other. Practice Contents Subtotal (100% Replacement cost) B. Practice Records/Charts, Account Receivables, valuable Papers, X-Rays; ............+... $25,000 minimum C. Dental Practice Blanket Limit Total (A + B) D. Signs not attached to building 18. Inflation Guard — Dental Practice Personal Property (May select quarterly increase from 1% - 5%) 19, Valued Practice Income . / Minimum daily limit of $300 / 32.5 days ay ineieaae 20. Employee Dishonesty: a. money/securities 3 4,008 b. welfare and pension plans $ /S500 7) 21. Rents (annual rental income) i $ 22. Dentist's Electronic Equipment (including Electronic Data Processing equipment) $ oF, 000 Do you use surge protection devices? 8 Yes @ No —_— 23. Equipment Breakdown Coverage? 6 Yes 6 No ® Dental Equipment only 8 Dental Equipment and Heating, Ventilation & Air Conditioning Equipment Do you own the building in which your office is located? 0 Yes @ No 24, Fine Arts (attach appraisals, if additional coverage is desired) -$10,000 subject to maximum $1,000 per item 25. Have you had any coverage declined or property losses (fire, burglary, water damage, premises, earthquake, etc.) or employee dishonesty losses during the past three (3) years? . 6Yes @No if “Yes”, please give details (cause of loss, amount paid, date of loss) on a separate sheet of paper. 26. Property Deductible - $250 (Optional Deductibles of $500, $1,000, $2,500, $5,000 and $10,000 available (Please contact your agent) G-151513-1 (1d. 05/2006) 2 EFTA00311432

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BUILDING INFORMATION - Co: 27. Building —- (Current Cost to Replace)..... a. additional buildings on premises (garage, storage ing b. inflation guard (may select quarterly increase from 1% - 5% .. Mandatory 28. Please indicate % of vacancy, or tenants by type of business and/or operations conducted, and square footage for each: Sq. feet: Sq. feet: 29. Is your building located on a known land subsidence area? W, |s your building resting on a saturated man-made (filled ground) or alluvial (soft) soil? ..0 Yes @No 31, Name of building owner: + 33. Describe the occupant to the right of Descnbe the occupant to the left of your Describe the occupant to the rear of your our building, including distance. building, including distance. building, including distance. | hereby acknowledge that the aforementioned statements and answers are correct and complete. | further understand that any incorrect or incomplete statement could void my protection. | hereby authorize the CNA Insurance Companies to release the information on this applicalion and associated underwriting information. FRAUD NOTICE — WHERE APPLICABLE UNDER THE LAW OF YOUR STATE Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false or incomplete information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES (for New York residents only: and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.) (For Pennsylvania Residents only: Any person who knowingly and with intent to injure or defraud any insurer files an application or claim containing any false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to seven year and payment of a fine of up to $15,000,) (For Tennessee Residents only: Penalties include imprisonment, fines and denial of insurance benefits.) Jolie (aon Signature in full: Dat G-151513-D (Ed. 05/2006) 3 EFTA00311433

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CVA The Professional Protector Plan® Claims-Made Professional Liability Insurance For Dentists THIS iS AN APPLICATION FOR CLAIMS MADE COVERAGE WHICH, SUBJECT TO ITS PROVISIONS, APPLIES ONLY TO ANY CLAIM FIRST MADE AGAINST THE INSUREDS DURING THE POLICY PERIOD. NO COVERAGE EXISTS FOR CLAIMS FIRST MADE AFTER THE END OF THE POLICY PERIOD, UNLESS, AND TO THE EXTENT, AN EXTENDED REPORTING PERIOD APPLIES jim 1. Please answer all questions. Do not leave any blanks. If a question is not applicable, please write N/A. 2. Application must be signed and dated by applicant. 3. A copy of your letterhead must be included. Also, please include @ copy of alll of your “Yellow Pages” advertising, if any. ! agree that any coverage issued will be contingent oF upon the truth of the following information: ‘LiMiTS REQUESTED: _ 3 Polic' Requested Effective Date: /0 [26/20 0 $3,000,000 / $6,000,000 © $2,000,000 / $4,000,000 | 0 $5,000.000 / $5,000,000 U $5,000,000 / $8,000,000 U Other: $ ee STATE EXCEPTIONS: IN, FL, KS, PR, NY, SC, VA) PLEASE TELL US ABOUT YOURSELF - 1. Name: (First/Middle initial/Last/Designation) Mops Uomo 2. Social Security Number. 3. Date of Birth: bw lia “Ss aa 7 4. Majling Add A BB ST Thos usvTr 00BOR Street City Stale Zip Code 6. Fax Number: 7. E-mail Address: a ee 8. Years f Practice: 9. Dental School Attended: 10. Month/Year of Graduation: Columb, Dowtl Schoo) May 015 11. Are you entering practice for the first time? if "Yes", did you complete a residency? Specialty: Month/Year of Completion: 12. Business structure under which you practice (Check all that apply): A. Q Employee O Independent contractor O Sole proprietor Q Incorporated O Partnership M@L.L.C. OL LP. O Professionat Association Q Professional Corporation O Other (describe) * Provide the name of the Legal Entity LLC + Oo you desire shared or separate limit of liability to apply to this entity? Shared (limits are shared with you) O Separate (entity has its own set of limits) 8. Besides yourself, list the names of all dentists who are partners/corporate officers for all legal entities: (\f additional space is needed, please list on a separate sheet of paper). (Note: All partners/ corporate officers must be Insured by CNA) Name Social Security No. Name Social Security No. Name Social Security No. Name Social Security No Name Social Security No. Name Social Security No C. If you own your practice, please provide the number of the following who work for you: # of full-time # of part-time Employee dentists (other than yourself and/or partners/corporate Officers)?..............00 (Attach separate application or proof of professional liability insurance) Independent Contractor dentists (Attach separate application or proof of professional kabitity insurance) All other employees (i.e., hygienist, dental assistants, technicians, etc.) G-19547-F (Ed. 05/06) I EFTA00311434

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D. Do you work for another dentist as an independent contractor dentist?... if “Yes", please provide the name of the employer/facility: — E. Do you work for another dentist as an employee dentist? .............ccccccccescssssseseessneeesseneessseaeeeneneeeeee if “Yes", please provide the name of the employer/facility: F. Do you share dental facilities with other dentists who are not covered under this Policy?............s0csesere OYes ZINo If “Yes", attach proof of professional liability insurance for the other dentists . Practice Addresses and Percentage of Practice at Each Address (Total of Percentages Must Equal 100%): Primary Street City County State ZipCode % Street City County State Zip Code % Street . Are you a member of your state dental association or society? . How many hours per week do you practice (include !ab work, patient visitation and consultation)? If 20 hours or less, please complete a Part-time Supplement 16. Are you currently licensed to practice Gentistry?...........ccssecessssecrssssnrsseesnesssesrsasonerssesasnearseanenseesanesenersecenenenee State(s): License #(s): 17. Have you taken one of the following risk management seminars in the last 3 years? O CNA €Evidence not required if you are a CNA insured) O Hartford GAAOMS OQ AAO O Princeton OQ NYSDA Date of Attendance i / If*Yes”, provide evidence of attendance. 18. Indicate your Practice Specialty = General Dentistry Q Periodontics QO Endodontics O Oral Radiology Q Prosthodontics O Oral/Maxillofacial Surgery Q Orthodontics Q Public Health O Oral Pathology O Pediatric Dentistry GO Full-time Faculty-Non-Intramural O Anesthesiology(Dental)-Conscious Sedation O Anesthesiology(Dental)-General Anesthesia 49, Which of the following procedures are performed by you: O Irreversible TMJ-Phase II (such as bridgework, surgery, orlhodontics undertaken primarily to treat a TMJ disorder) Q Implant Surgery O “Sargenti", paste fill or similar endodontic techniques Oxf Extraction of Impacted teeth O Implant Restoration O Molar Endodontics on Permanent Teeth O Sleep Apnea Therapy If “Yes”, please indicate the following: G | treat only after referral from physician © | treat without physician referral Q | fabricate snore guard © Weight Loss Therapy, including DDS System If “Yes”, please indicate the following: O | treat only after referral from physician 0 | treat without physician referral DDS System Certification Date: © Cosmetic dermal procedures (including Botox, restinor hyaluronic acid products, collagen injections, dermabrasions, etc.) If “Yes”, please provide an explanation on a separate sheet of paper. O Consulting Services (Rendering advice or recommendations, practice management consulting, expert witness testimony) If"Yes", do you desire coverage? O Yes Q No O None . A. Have you ever had a change in the status of your hospital privilegeS?.............0-cscserseessereresereneeeenensersneenes if "Yes", provide details on a separate sheet of paper. B. Has any governmental agency, including a state licensing board, ever taken action against either your dental lor narcotics license including suspension, revocation, probation, restriction, denial or other sanctions? ..... OY No If "Yes", provide a copy of the board transcript or other documentation, including resolution. C. Have you been under investigation or currently under investigation by any governmental agency including a state licensing board or other regulatory AGENCY? ..........eccsccesseseeseevecnestssesneseessesesusstsueensnseneens — sneeneenssaserseses O YesXI No If "Yes", provide a copy of the board transcript or other documentation, including resolution. D. Have you been convicted of any criminal Charges?.............-rssesnesessecnnssneeeseenrannnesnsutensnrsrersersnes —orsessees If "Yes", provide details from investigating agency. E. Have you ever been treated for alcoholism, drug addiction, mental illness or physical impairment? ......... QO Yes No If *Yes*, provide a letter from treating physician with complete details. G-19547-F (Ed. 05/06) 2 EFTA00311435

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PLEASE TELL US ABOUT YOUR USE OF ANESTHETICS AND ANALGESIA Please be sure to read and answer all parts very carefully. For purposes of these questions, the following definitions of Anxlety Reduction, Conscious Sedation and General Anesthesla/Deep Sedation are provided: Anxiety Reduction is defined as “the use of nitrous oxidefoxygen and/or oral premedicalion used in an accepted therapeutic dose to reduce anxiety.” Conscious sedation is defined as: “A minimally depressed level of consciousness thal retains the patient's ability to independently and continuously maintain an airway and respond appropriately to physical stimulation and verbal command, produced by a pharmacologic or non-pharmacologic method, or a combination thereof." General Anesthesia and Deep Sedation are defined as: “A controlled stale of depressed consciousness or unconsciousness, accompanied by partial or complete loss of protective reflexes, Including inability to independently maintain an airway and respond purposely to physical stimulation or verbal command, produced by @ pharmacologic or non-pharmacologic method, or a combination thereof.” 21. A. Is your practice limited to the use of local anesthesia, oral medication and/or nitrous oxide?....................a Yes Q No B. Are you treating patients who are under conscious sedation? ce aa teengtaneneeteeeneeeeney I Yes Q No C. Are you treating patients who are under general anesthesia / deep sedation?.. If“Yes”, where are the procedures performed? . QO Inyour office Q In a hospital or surgical center If “In Your Office”, who administers the anesthesia? . OYou O Another Dentist, Anesthesiologist or CRNA PLEASE TELL US ABOUT YOUR INSURANCE HISTORY Do not complete questions 22 through 29 if you are a current PPP insured. 22. Are you now, or have you ever, practiced without professional liability insurance? if“Yes", provide dates and reason: 23. Have you ever had any professional liability insurance refused, cancelled or non-renewed?. If"Yes", provide dates and reason: (NOT APPLICABLE FOR MO) 24, Has any claim or suit for alleged malpractice ever been brought against you? If "Yes", please complete Supplemental Claim form. 25, Are you currently aware of any situation that could lead to a malpractice suit Against YOU?..........cecesnesnees If “Yes”, please complete Supplemental Claim form. 26. List prior carrier(s) for the past three (3) years | If none, state “None.” insurer Expiration oe Date 27. Are you applying for prior acts coverage from CNA? if "Yes", please attach a copy of your last declaration page (face sheet). G-19547-F (Ed. 05/06) 3 EFTA00311436

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PLEASE TELL US ABOUT YOUR PREMISES/OPERATIONS 30. If your equipment lease or rental requires you to name the equipment lessor as an additional insured, nvApiease provide the name and address of the lessor as it appears on the lease or rental agreement: oS oy i GIO fd TOU Ora bs 7} Fh 32. Have you had any general liability losses in the past three (3) years? If "Yes", provide date(s) of loss and detail(s). 33. Do you want ERISA Fiduciary Liability coverage ($100,000 Limit of Liability)? . Coverage is recommended if you sponsor any Employee Benefit Plan. Coverage is written on a Claims-made basis. | hereby acknowledge that the aforementioned statements and answers are correct and complete. | further understand that any incorrect or incomplete statement could void my protection. | hereby authorize the CNA Insurance Companies to release the information on this application and associated underwriting information. | understand (hat my Professional Liability Coverage will be written on a “Claims-Made form" and acknowledge that this coverage will only respond to claims which are reported during the term of this policy. | also acknowledge that my "Claims-Made" coverage will not provide insurance coverage for claims which occurred prior to the “Prior Acis Date” of my policy. | understand that, should my “Claims-Made" policy with this insurance carrier ever be cancelled or non-renewed, or | decide to terminate it for any other reasons, and | desire to provide insurance protection for any claims which may have occurred during the term of the "Claims- Made" policy, but were not reported to the insurance company before the date of the policy termination, | will be able to purchase additional insurance coverage. FRAUD NOTICE - WHERE APPLICABLE UNDER THE LAW OF YOUR STATE Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false or incomplete information, or conceals for the purpose of misleading, information concerning any fact material thereto, commils a fraudulent insurance act, which is a crime AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES (for New York residents only: and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.) (For Pennsylvania Residents only: Any person who knowingly and with intent to injure or defraud any insurer files an application or claim containing any false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to seven year and payment of a fine of up to $15,000.) (For Tennessee Residents only: Penalties include imprisonment, fines and denial of insurance benefits.) COMPLETION OF THIS FORM NEITHER BINDS COVERAGE NOR GUARANTEES A POLICY WILL BE ISSUED. Signature in full: Date G-19547-F (Ed. 05/06) 4 EFTA00311437

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REMINDER: Please attach a sample of your letterhead and a copy of all of your dental practice "Yellow Pages" advertising, if any, to this application. RETURN TO: State Administrator Name: Phone #: ( ) Agent's License Number: The Professional Protector Plan® is a registered trademark of Brown & Brown, Inc.®. Coverage is underwritten by Continental Casualty Company, one of the CNA property/casualty insurance companies. CNA is a service mark registered with the US Pater and Trademark Office. G-19547-F (Ed. 05/06) 5 EFTA00311438