GA, SD, WV
Multistate
PI-PLSP-BTSUPP 09/11 Page 2 of 3
10. Provide the following information on the Applicant's lawyers professional liability (E&O) insurance for the past
three (3) years:
Check here if lawyer/attorney services are not performed by Applicant.
Check here if lawyer/attorney services are performed by Applicant but professional
liability (E&O) coverage is not in place.
Name of Insurer Limits of Liability Deductible Policy Period Premium
$ $ $
$ $ $
$ $ $
11. Is the Applicant acting as a Trustee in any Chapter 11 cases? Yes No
If no, skip questions 12 through 13.
Applicant understands that no coverage exists for Trustee services involving
Chapter 11 cases unless specifically endorsed on this policy or a separate case-
specific policy
.
Yes
No
12. Please list all Chapter 11 trusts to which the Applicant is currently appointed:
(To enter more information, please use the Additional Info page below)
Trust Name:
Value of Trust:
Debtor’s Nature of Operations:
Is the debtor publicly traded, privately held, or non-p
rofit:
Is professional liability coverage currently in place for any of the above cases? Yes No
If yes, provide details:
13. The following documents must be attached to this supplement for each Chapter 11 case:
Trustee Agreement
Trust Plan
Disclosure Statement
Trust Financial Statements
Court Appointed Document
I understand that the information submitted herein becomes a part of my Philadelphia Insurance
Companies Cover-Pro
sm
application and is subject to the same conditions as stated on that application.
Name (Please Print/Type) Title
(MUST BE SIGNED BY A PRINCIPAL PARTNER OR OFFICER)
_______________________________________
Signature Date
