Personal Catastrophe Liability Application

Are you a member of the AICPA or an employee of a firm with AICPA membership?*

Yes No

If "No" you are not eligible for Personal Liability Insurance under the AICPA Insurance Programs.

If Yes, enter account number:

$1 Million $2 Million $3 Million

As a normal procedure in the insurance industry, a routine inquiry may be made to verify information on your insurance application. The Federal Fair Credit Reporting Act requires us to notify you that a consumer report or an investigative report may be requested by us to verify information which could include driving experience, general reputation, personal characteristics, character, and mode of living. This report is confidential and available to you upon written request.

Applicant Statement: I have read the above application and I declare that to the best of my knowledge and belief all of the foregoing statements are true. (Kansas: This does not constitute a warranty.)

UNINSURED AND UNDERINSURED MOTORIST COVERAGE (UMC) NOTICE APPLICABLE TO MEMBERS LIVING IN FLORIDA - $1 MILLION LIMIT; INDIANA, LOUISIANA, NEW HAMPSHIRE, VERMONT, WEST VIRGINIA AND WYOMING. UMC is insurance for possible injury to you caused in an automobile accident by someone who has no insurance or inadequate insurance. PLUS Plan insurance covers your liability to others. UMC is not available in most states including SOUTH DAKOTA.

I have been offered the opportunity to purchase UMC under the PLUS Plan. I elect not to include UMC under the PLUS Plan. It is agreed that this rejection of UMC will hold in any renewal, supplementary, replacement or substitute policy.

Yes

I have read the UMC Notice and I reject the coverage on behalf of all who are to be covered by this policy.
(If you do not reject the UM coverage by checking yes, your policy will include UMC coverage with the additional premium.)

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, including but not limited to fines, denial of insurance benefits, civil damages, criminal prosecution and confinement in state prison.

Affinity Insurance Services Inc. is an insurance producer licensed in your state. Insurance producers are authorized by their license to confer with insurance purchasers about the benefits, terms and conditions of insurance contracts; to offer advice concerning the substantive benefits of particular insurance contracts; to sell insurance; and to obtain insurance for purchasers. The role of the producer in any particular transaction involves one or more of these activities. Compensation will be paid to the producer, based on the insurance contract the producer sells. Depending on the insurer(s) and insurance contract(s) the purchaser selects, compensation will be paid by the insurer(s) selling the insurance contract or by another third party. Such compensation may vary depending on a number of factors, including the insurance contract(s) and the insurer(s) the purchaser selects. In addition, Affinity may charge a fee for administrative services. Your signature on your application, quote form, check and/or other authorization for payment of your premium, will be deemed to signify your consent to and acceptance of the terms and conditions including the compensation, as disclosed above, that is to be received by Aon. The insurance purchaser may obtain information about compensation expected to be received by the producer in whole or in part on the sale of insurance to the purchaser, and compensation expected to be received based in whole or in part on any alternative quotes presented to the purchaser by the producer, by contacting member services at 800-223-7473.

In addition, premiums paid by Clients to Affinity for remittance to insurers, Client refunds and claim payments paid to Affinity by insurance companies for remittance to Clients are deposited into fiduciary accounts in accordance with applicable insurance laws until they are due to be paid to the insurance company or Client. Subject to such laws and the applicable insurance company's consent, where required, Affinity will retain the interest or investment income earned while such funds are on deposit in such accounts.

In placing, renewing, consulting or servicing your insurance coverages Affinity and its affiliates may participate in contingent commission arrangements with insurance companies that provide for additional contingent compensation, if, for example, certain underwriting, profitability, volume or retention goals are achieved. Such goals are typically based on the total amount of certain insurance coverages placed by Aon with the insurance company or the overall performance of the policies placed with that insurance company, not on an individual policy basis. As a result, Aon may be considered to have an incentive to place your insurance coverages with a particular insurance company.

Aon Corporation, our ultimate parent company, and its affiliates have from time to time sponsored and invested in insurance and reinsurance companies. While we generally undertake such activities with a view to creating an orderly flow of capacity for our clients, we also seek an appropriate return on our investment. These investments, for which Aon is generally at-risk for potential price loss, typically are small and range from fixed-income to common stock transactions. In such case, the gains or losses we make through your investments could potentially be linked, in part, to the results of treaties or policies transacted with you. Please visit the Aon website at http://www.aon.com/market-relationships for a current listing of insurance and reinsurance carriers in which Aon Corporate and its affiliates hold any ownership interest.

Aon Corporation's operating affiliates are parties to numerous agreements with many insurance and reinsurance companies, including companies from which our clients have purchased insurance or reinsurance. Please visit http://www.aon.com/market_relationships for more detail on these agreements.

By submitting this application electronically, I understand that the premium quoted is based on standard rating and before final acceptance by the insurer, this Application does not constitute a binder, the Application may be denied or accepted and the coverage limit may be reduced, and I acknowledge reading the Application and the underlying liability insurance requirements.

The following insurance types and amounts, as applicable, are required for your full personal liability protection with the PLUS Plan. *

And your PLUS Plan adds personal injury liability protection against claims arising from...

• Libel
• Slander
• Defamation of character
• False arrest
• Detention
• Wrongful entry
• Wrongful eviction
• Malicious prosecution
• Invasion of the right of privacy

This information is intended to present a general overview for illustrative purposes only. It is not intended to constitute a binding contract. Please remember that only the relevant insurance policy can provide the actual terms, coverages, amounts, conditions and exclusions for an insured. All products and services may not be available in all states and may be subject to change without notice. CNA is a service mark registered with the United States Patent and Trademark Office. Copyright © 2009 CNA. All rights reserved.

Click here to contact the customer service rep, or call us toll-free at 1-800-223-7473.