MALP 0015 07 13 Page 2 of 3
4.
During the past five (5) years, to the best of your knowledge, have any of the following ever
happened relative to any LP which you formed or ever provided any other services relative to, at any
time? Please check either Yes or No for each question. If Yes to any part of Question 4. below,
please attach complete details on a separate sheet.
a. Publicly traded limited partnership units were de-listed or otherwise ceased trading on any public
securities exchange?
Yes No
b. Any LP, or any general or limited partner received notice of any kind of alleged tax deficiency
from the Internal Revenue Service or any state tax or revenue department?
Yes No
c. Any individual, derivative, or class action litigation has been brought by, or on behalf of, any of
the limited partners against the managing general partner or any other party?
Yes No
d. Any LP has ceased operations, become bankrupt or insolvent, or has gone into receivership,
trusteeship, liquidation, or dissolution?
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:
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 Hawaii Applicants: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim
for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.
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.
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