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U.S. Risk | 14241 Dallas Parkway, Suite 850, Dallas, Texas 75254 Insurance Agents E&O Application PAGE 1 OF 7U.S. Risk is a Division of Innovation Growth Partners Specialty, LLC | Rev.

StaffPak is a Specialty Program of U.S. Risk, LLC | Rev. 05.2022 PEO Abuse and Molestation Supplemental Application U.S. Risk, LLC | 8401 N. Central Expressway, Dallas, Texas 75225

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Managed by: Scott Carroll, Director of Take1 1551 N. Tustin Ave., Suite 430 Santa Ana, CA 92705 Phone: (800)856-7035 scott@take1insurance.com Application For Event/Party Planners and

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Incorporated by Reference in Rule 69O-189.003 ACORD 130 FL (2019/07) LOCATIONS - LIST ALL PHYSICAL LOCATIONS, INCLUDING OTHER STATES, WHETHER COVERAGE IS REQUESTED OR NOT. IF APPLICANT IS

© Copyright 2018 National Council on Compensation Insurance, Inc. All Rights Reserved. 1  ERM-14 Form Instructions How to Submit The ERM-14 Form is available on the Frequently Accessed Forms

08/26/2014 1           APPLICATION FOR EXCESS WORKERS’ COMPENSATION      Date:              Submitted By:                  Producer:              Insured:              Address:               

PAGE 1 OF 7 Financial Services Protection Insurance Application Administered by THIS IS AN APPLICATION FOR INSURANCE WRITTEN ON A “CLAIMS MADE AND REPORTED” BASIS WHICH APPLIES ONLY TO CLAIMS

APPLICATION Life and Health Insurance Agents and Brokers Errors and Omissions Insurance Underwritten by Utica Mutual Insurance Company New Hartford, New York THIS IS AN

SEPTEMBER 2022 T H E S T A T E O F F R A U D A N D F I N A N C I A L C R I M E I N T H E U. S. T A B L E O F C O N T E N T S Introduction . . . . . . . . . . . . . . .

Gary Atkins (281) 243-5722 garya@usrisk.com Casualty | Residential, Commercial and Industrial Contractors; Products Liability; Oil and Gas Lease Operators; Oil and Gas Contractors and Consultants

Downhole Tool SPECIALIZED DRILLING EQUIPMENT INSURANCE Downhole Tool Insurance covers the replacement cost of scheduled tools in the event they become irretrievably lost while below the rotary

Page 1 of 3 INSURED INFORMATION NAMED INSURED INSURED ADDRESS CITY STATE ZIP WELL DETAILS WELL NAME CLOSEST ADDRESS CITY STATE ZIP WELL DEPTH ft COVERAGE COVERAGE BASIS Total

Specialty Underwriting | SWD Program REV 12.02.2020 Building solid, professional relationships is the foundation of success. U.S. Risk is committed to this concept and considers it one of the

Specialty Underwriting | Oil & Gas Program Building solid, professional relationships is the foundation of success. U.S. Risk is committed to this concept and considers it one of the most

PROFESSIONAL LIABILITY ■ Defense outside limit option available ■ Personal injury included when related to professional services ■ Contingent BI/PD coverage available ■ Claims Made and

Take1 is a division of U.S. Risk, LLC and its affiliate companies. U.S. Risk, Take1, and the Take1 logo are registered trademarks of U.S. Risk Insurance Group, Inc. Copyright ©2022 U.S. Risk

Take1 is a division of U.S. Risk, LLC and its affiliate companies. U.S. Risk, Take1, and the Take1 logo are registered trademarks of U.S. Risk Insurance Group, Inc. Copyright ©2022 U.S. Risk

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