Fillable Form 1.: CORPORATE MERGERS OR ACQUISITIONS SUPPLEMENTAL APPLICATION (Risk Placement Services, Inc.)

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Form 1.: CORPORATE MERGERS OR ACQUISITIONS SUPPLEMENTAL APPLICATION (Risk Placement Services, Inc.)

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MALP 0008 07 13 Page 1 of 3
CORPORATE MERGERS OR ACQUISITIONS SUPPLEMENTAL APPLICATION
NOTE:
For purposes of this Supplemental Application, the following definitions apply:
1.
"Corporate Merger" means any combining of the assets and liabilities of two corporations into a single
surviving corporation.
2. "Corporate Acquisition" means the acquisition of all or a majority of the outstanding shares of stock of one
corporation by any other corporation or other party.
APPLICANT’S INSTRUCTIONS:
This form is to be completed if the Applicant showed any activity in the Corporate Mergers/Acquisitions area of practice
shown in Section II. "Applicant's Practice," on the main application. If space is insufficient to answer any question fully,
attach a separate sheet. Answer all questions completely.
APPLICANT:
1. How many of each of the following situations have you performed legal services or advice for during the past three (3)
years?
Merger of Publicly Held Companies:
Merger of Privately Held:
Acquisition of a Publicly Held Company:
Acquisition of a Privately Held Company:
Other (Describe):
2. Please complete the following relative to the three (3) largest mergers and also for the three (3) largest acquisitions for
which you have rendered any legal services or advice during the past three (3) years:
MERGERS - TOTAL POST MERGER ASSET SIZE ACQUISITIONS - TOTAL APPROXIMATE PURCHASE
PRICE
1. $
1. $
2. $ 2. $
3. $
3. $
3. Check each box below if you have provided this kind of service relative to any corporate merger or acquisition during
the past three (3) years:
Corporate Due Diligence - analysis of documents or records.
Corporate Due Diligence - interview of corporate management.
Assist in negotiating the terms of the merger or acquisition.
Drafting of the merger or acquisition contract.
Rendering of any kind of tax advice.
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
MALP 0008 07 13 Page 2 of 3
Rendering advice or services on governmental regulatory issues.
Registration of securities.
Providing business related consultation or advice.
4. For all of the mergers and acquisitions shown in Question 1., did you provide the client, in advance
of your representation, with a written engagement letter which clarified the exact nature and scope
of legal services that you would be providing?
Yes No
5. a. Do you have formal written procedures in effect which address is
sues relative to the
permissibility of buying or selling the stock of a client of the Applicant, along with addressing
insider trading issues?
Yes No
b. If Yes, are there written potential penalties in place for violation of the procedures, including
termination from the Applicant?
Yes No
6. During the past three (3) years, have any of the following ever occurred relative to any corporate
merger or acquisition for which you rendered any kind of legal or other services? Please check Yes
or No for each question. If Yes to any part of Question 6. below, please attach complete details on a
separate sheet.
a. In a corporate acquisition, you represented both the acquiring party and also the corporation
being acquired, or its majority shareholders?
Yes No
b. In a corporate merger, you represented both of the corporations being merged, or their majority
shareholders?
Yes No
c. An agreed to merger or acquisition did not consummate for any reason?
Yes No
d. As the result or byproduct of a merger or acquisition, any shares of stock or other securities
were retired or were de-listed or ceased trading on any stock exchange?
Yes No
e. The corporate merger or acquisition could be characterized as being "hostile," or against the
desire of the current management of the company being acquired?
Yes No
f. Any civil litigation of any kind by any parties relative to the merger or acquisition?
Yes No
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:
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MALP 0008 07 13 Page 3 of 3
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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Form 1.: CORPORATE MERGERS OR ACQUISITIONS SUPPLEMENTAL APPLICATION (Risk Placement Services, Inc.)

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Completed 23 November 2020

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