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COLLECTION WORK SUPPLEMENTAL APPLICATION (Risk Placement Services, Inc.)

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MALP 0007 07 13 Page 1 of 2
COLLECTION WORK SUPPLEMENTAL APPLICATION
NOTE: For purposes of this Supplemental Application, the term "Collection" means any activity relative to collecting or
attempting to collect any personal or consumer debt. The term "Collection" also means any kind of advice or legal or
other services provided to any party who was or is involved in any way in collecting or attempting to collect any personal
or consumer debt.
APPLICANT NAME:
1. During the past two (2) years, approximately how many different individual consumer debtors have
been contacted by phone, letter, e-mail, fax or otherwise, by anyone presently or formerly employed
by, or in any way affiliated with the Applicant?
2. During the past two (2) years, how many lawyers, non-lawyer employees, independent contractors or
other persons or entities in any way affiliated with the Applicant have been involved in contacting
consumers relative to debts owed or any other kind of consumer debt collection activities?
3. a. During the past two (2) years, have you allowed any collector, collection agency, or other party to
use the Applicant's name or any of your lawyer's names in any collection-related letter?
Yes No
b. If Yes, please explain in detail:
4. a. During the past two (2) years, have you provided any kind of advice or opinion to any party
relative to their development or implementation of any debt collection procedures, or relative to
whether any kind of collection letter or collection-related activity of theirs would be in compliance
with the provisions of the federal Fair Debt Collection Practices Act, or any related or similar
federal or state statute or regulation?
Yes No
b. If Yes, please explain in detail:
5. a. Within the past two (2) years, has any lawyer presently or formerly associated with the Applicant,
or their past or present spouse, had any beneficial ownership interest of any kind in any
collection agency?
Yes No
b. If Yes, please explain in detail:
I understand the information submitted herein becomes a part of my Professional Liability Insurance Application and is
subject to the same representations and conditions.
Notice to Florida Applicants: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a
statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony in the
third degree.
Notice to New York Applicants: 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 information, or conceals for
the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a
crime, 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.
Signature of Owner, Officer or Partner Print or Type Name and Title Date (month-day-year)
Producers Must Complete:
Produced By (Insurance Agent or Broker):
Producer Name: Producer Signature:
Producer License No.: Date:
Broker Name
Broker Street
Broker City, State, Zip
Deerfield Insurance Company
Evanston Insurance Company
Essex Insurance Company
Markel American Insurance Company
Markel Insurance Company
Associated International Insurance Company
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MALP 0007 07 13 Page 2 of 2
Notice to Alabama Applicants; Any person who knowingly presents a false or fraudulent claim for payment of a loss or
benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject
to restitution, fines, or confinement in prison, or any combination thereof.
Notice to Arkansas, District Of Columbia, New Mexico, Rhode Island And West Virginia Applicants: Any person
who knowingly presents a false or fraudulent claim for payment of a loss or benefit, or knowingly presents false information
in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Notice to Colorado Applicants: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to
an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include
imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who
knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of
defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance
proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
Notice to Kansas Applicants: It is unlawful to commit a “fraudulent insurance act” which means an act committed by
any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or
belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as
part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial
insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance
which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the
purpose of misleading, any information concerning any fact material thereto.
Notice to Kentucky Applicants: Any person who knowingly and with intent to defraud any insurance company or other
person files an application for insurance containing any materially false information or conceals, for the purpose of
misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.
Notice to Maine, Tennessee, Virginia and Washington Applicants: It is a crime to knowingly provide false, incomplete or
misleading information to an insurance company for the purpose of defrauding the company. Penalties may include
imprisonment, fines, or denial of insurance benefits.
Notice to Maryland Applicants: Any person who knowingly or willfully presents a false or fraudulent claim for payment of
a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime
and may be subject to fines and confinement in prison.
Notice to New Jersey Applicants: Any person who includes any false or misleading information on an application for an
insurance policy is subject to criminal and civil penalties.
Notice to Ohio Applicants: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an
insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Notice to Oklahoma Applicants: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any
insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is
guilty of a felony.
Notice to Pennsylvania Applicants: 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 information or conceals for the
purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime
and subjects such person to criminal and civil penalties.
Notice to Vermont Applicants: Any person who knowingly presents a false statement in an application for insurance may
be guilty of a criminal offense and subject to penalties under state law.
Notice to Applicants of all other states: 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 information or conceals for
the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a
crime and subjects the person to criminal and civil penalties.
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COLLECTION WORK SUPPLEMENTAL APPLICATION (Risk Placement Services, Inc.)

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Completed 23 November 2020

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