Professional Liability Insurance Application for IICT Members

Section I: APPLICANT INFORMATION

Allied Health Occupation for which Professional Liability coverage is being applied for:

(Please attach a current license if required or other evidence of your certification as anAllied Health Professional as described above.)

Applicant’s Name:

Mailing Address: City: State: Zip:

E-mail Address:

Daytime Phone: Evening Phone: Fax: Date of Birth:

Section II: EMPLOYMENT/OCCUPATION INFORMATION

Indicate your total number of years experience relevant to the profession for which you are seeking coverage.

Total: (Be sure to include any time you may have worked under supervision) o Employed* o Self-Employed Full-time (25 hours or greater)** o Self-Employed Part-time (less than 25 hours a week)** o Student - Anticipated Graduation Date: Student’s Permanent Address:

City: State: Zip:

Student’s Permanent E-mail:

*Are you or your spouse also a shareholder or have an equity position exceeding 5% in your employer? o Yes o No

*Are you incorporated (including Sub chapter S Corporations), a partner, owner or officer to your employer? o Yes o No

**Are there any other individuals, employed or associated with otherwise, providing professional services on your behalf, or on behalf of an entity in which you or your spouse has an ownership interest? o Yes o No

Highest degree obtained: o High School | Graduation Date: MM/DD/YY ______o Associate | Graduation Date: MM/DD/YY ______o Bachelors | Graduation Date: MM/DD/YY ______o Masters | Graduation Date: MM/DD/YY ______o Doctorate | Graduation Date: MM/DD/YY ______

Please indicate your profession for which you are seeking coverage from our listing of eligible covered occupations: ______

1. Does your post High School education qualify you for the profession for which you are seeking coverage? o Yes o No If yes, explain: 2. Are you a member of any professional association related to your occupation? o Yes o No If yes, provide information association name: 3. Are you: o Licensed o Certified o N/A

Administered by Lockton Affinity, LLC IICT Individual Application 6-2017 4. Are you able to work in your state without licensure or certification? o Yes o No 5. Do you provide any professional services to residents in/on the premises of any long-term care facility, i.e. nursing home or residential care facility? o Yes o No 6. Do you provide any type of youth-focused overnight professional programs such as Outward-Bound, boot camps, etc? o Yes o No 7. Do you provide any professional services to professional athletes whose annual income is $25,000 or greater? o Yes o No 8. Have you used or do you plan to use any life sustaining or critical life monitoring equipment or devices in your practice other o Yes o No than emergency defibrillation devices, i.e. an Automated External Defibrillator (AED)? This includes oxygen and other medical gases used in conjunction with respiratory therapy, dialysis or heart lung machines, SIDS monitors or any other life dependent monitors or equipment or devices that malfunction and could result in death or serious deterioration of a patient’s health condition.

9. Do you perform or plan to perform any jobsite training or consulting such as would normally be performed on a construction jobsite o Yes o No or in a manufacturing or factory setting by a safety inspector, safety trainer, or environmental inspector or consultant?

10. Will any new services be offered or current services discontinued in the next twelve (12) months? o Yes o No 11. Have any services been discontinued in the last 24 months? o Yes o No 12. If you responded “Yes” to any of the questions numbered 5-11 above, please provide full details: ______

Section III: PROFESSIONAL LIMITS AND COVERAGE

Indicate the Limits of Liability you would like: o $2,000,000 / $4,000,000 o $1,000,000 / $3,000,000 o $1,000,000 / $1,000,000 o $500,000 / $500,000 o $250,000 / $500,000 o $100,000 / $300,000

Are you listed as the Named Insured under another currently in-force Professional Liability Claims Made Policy covering acts for the same occupation as applied for here? o Yes o No Would you like to purchase a policy which provides coverage for acts back to your current policy Prior Acts Retroactive Date? o Yes o No

(If “Yes” to both questions above, please provide a copy of your current Claims Made Declarations Page and evidence of the prior acts retroactive date which may be listed on the Declarations Page or in an attached endorsement to your policy.)

*NOTE: You will need to provide Underwriters with a copy of your expiring policy to verify your current prior acts retroactive date should a claim be presented in the future under this program.

If you are Self-employed, the sole owner and have no employees, then your business name can be included at no additional charge. List business name, if applicable:

Section IV: CATEGORIES o Group Counceling Coverage Indicate which individual activities for which coverage is requested.

GROUP 1: Base premium $117 o AcuPoint Therapy o Consciousness Coaching o Integrated Listening Systems and Dynamic Listening Systems o Art Psychotherapy o Counselling o Health Coaching o Journey to Wellness o Art Therapy o Counselling - Progressive o Health Coach - Integrative Healing o Life Coaching o Biocentric Psychoanalysis o Counselling - Supervision o Holistic Counselling o Lifestyle, Food & Wellness o Biomagnetic Healing o Counselling- On-line o Holistic Health Coach Coaching o Body Love Coach o Creatrix Transformology o Holistic Integrated Creative Art o Therapy Lifestyle Prescriptions® Health o BrainWorking Recursive Therapy o Eco Art-Therapy Coach o o o Ecopsychology How to get a Bigger Bite out of Life Business Coaching o Living Threads o o o Effectiveness Training Human BioAcoustics Circle Facilitator o Masculine and Feminine Coaching o o o Emotional Anatomy Inner Child Therapy Cognitive Behavioural Therapy (CBT) ‡ o Mediation o o o Goddess for Life Coach Inner Personal Development Colour Coaching o Mentor (Counselling) o o o Group Counceling Integrative Coaching Conscious Uncouple Coaching o NES Assessment & Treatment

Administered by Lockton Affinity, LLC IICT Individual Application 6-2017 GROUP 1 COUNTINUED: Base premium $117 o Narrative Therapy o Psychoanalysis o Sandplay o Transpersonal Art Therapy o Neuro Life Coach o Psychodrama o Therapies o Transpersonal Counselling o Nonviolent Communication o Psychotherapy o Soul Link o The Sister Circles Facilitator o Ontological Coaching o Pyschophysics o Speech Pathology † o The Joyality Program o Passion and Purpose Coaching o Quantum Emotional Healing™ o Spiritual Counselling o Programs of the Heart o Restoration o Stress Management † o Progressive Counselling o Sacred Circles o Telephone Counselling †

GROUP 2: Base premium $178

o Advanced Fertility Nutritional o Exercise Advice o Meet Yourself Energy Meditation o Slings Myofascial Training Advisor (as part of overall treatment) (for mothers) o Sports Coaching o Advanced Gut Restoration o Exercise Physiology o Meet Yourself Protection o Sports Training - Fitness † Nutritional Advisor o Fitness Instruction o Natural Breastcare o Sports Psychology o Advanced Stress Management o Five Tibetan Rites o Natural Health Consultant Advisor o Stillness in Movement o Gitananda Yoga o NIA Technique o Aerobics Instruction o Tai Chi o Gyrotonic/ Gyrokinesis o Nutritional Consultant o Ageless Grace o Tai Chi for arthritis o Hasya Yoga (Laughter Yoga) o Personal Training o Antigravity Yoga o Tai Chi for diabetes o Hatha Yoga o Pilates o Artistic Eurythmy o Tantra o Healing Dance o Pilateyko Pilates Angel Swimming o Bones For Life o The Art of Feminine Presence™ o Integrative Health Practitioner o Pole Pilates o Callanetics Exercise Method o Tone N Go Yoga o Iso-Chi o Poliquin™ BioSignature Modulation o Chair Yoga o Vibrational Exercise Therapy o Kids Yoga o Posture Dynamics o Chi Moves o Wellbeing Consultancy and Coaching o Kriya Yoga o Power Yoga o Chi Running® o Wellness Consultancy and Coaching o Kundalini Yoga o Prenatal Yoga o Chi Walking® o Whole Woman® o Laughter Wellness o Purna Yoga o ChiBall o Wu Tao o Laughter Yoga o Qoya o Corrective Exercises o Yoga o Let Your Yoga Dance o Rainbow Children o Dance Movement Therapy o YogaBugs o Meet Yourself Energy Healing o Rosen Method Movement o Dancing for Birth o Yogalates o Meet Yourself Energy Meditation o Shaking Medicine o Energy Yoga o Zumba ‡ o Meet Yourself Meditation o SIMPLE Movement Programme o Eutony (for children) o Sleep Consultant

GROUP 3: Base premium $193 o Access Conciousness (Access Bars) o Angel Card Reading o Arolo Tifar o Bach Flower Remedies o Access Bars o Angelic Healing o AromaBliss o Bicom Instrument o Access EFT o Angel Intuitive o Aromatherapy o Biodanza o Accusense 232 Assessment o Angel Therapy Practitioner o Aromatherapy (Flower Essences) o Bio Energetics Medicine o Accusonic Plus Ultrasound Machine o Animal B.E.S.T. (Bio-Energetic o Aromatherapy on Horses o Bio Feedback o Acu-energetics Synchronziation Technique) o Aromatic Medicine o Biograph Assessment o o Acutonics Animal Communication o Ashati o Bioimpedance Analysis o o Advanced Child and Brain Animal Dreaming o Aston Patterning o Birth Skills™ o Development Nutritional Advisor Animal Training - Dogs & Cats o (incl. Chinese Astrology) o Body Acceptance & appreciation o o Advanced Sports & Exercise Anthroposophy (spiritual philosophy) o Asyra Device for women † Nutritional Advisor o o Aqua Detox o Audio Sound Body Acceptance & appreciation o African Drumming o for youth † Aqua Detox Medical Unit o Aura-Soma® o Aka Lani o o Body Love Intuitive Aquarian Healing o Autogenic Training o Alexander Technique o o Bioresonance Therapy Aquatic Bodywork o Avatar Assessment o Allergy Kit Allergy Relief Treatments o o Biosenetics Arolo o BabyCalm™ Administered by Lockton Affinity, LLC IICT Individual Application 6-2017 GROUP 3 CONTINUED: Base premium $193 o Body Connect Healing o Crystal Shamanism-Rachelle Charman o Free to Be Me o Lifeline Technique *† o Body Composition Test ‡ o Crystal Sound Therapy o Functional Diagnostic Nutrition o Lightworker Practitioner o Body Electronics Point Holding o Crystal Therapy o Gem Essences o Listen/EQ4/Orion Assessment o Body Mind Resolution (BMR) Healing o Demartini Method o Geomancy o Living Authentically® o Body Network & Beyond o Diamond Light Practitioner o Gestalt Therapy o Living Love o Body Psychotherapy o Direction Technique o Hahnemann Healing o Mace Energy Method o Body Stress Release o Didgeree Doo Sound Healing o Hakomi o Magnetabiology o Body Talk Systems o Dietary Consultant (Nutritional o Heal Your Life o Manifestation Coaching Counselling) o Brain Gym o Heart Energetics o Meditation o Diversional Therapy o Brainwave Optimisation® o HeartMath o Mediums / Channeling o Divine Lightworker o Breathwork o Heart Resonance Therapy o Meet Yourself Therapy o Divine Source Enhancement Healing o Breathworks Mindfulness o Hexagram of Balance o Meliae Intuitive Healing o DLF Therapy o Brennan Healing o Holistic Energy Care o Metatronia Therapy® o Down Size Me Food Coaching o Bush Flowers o Holistic Healing o Metaphysical Anatomy o o California Flowers (Energy Healing only) o Holographic Repatterning / Technique (MAT) o o o Calmbirth® † Dream Work/Interpretation Resonance Repatterning Mickel Therapy o o o o Celluloid Mineral therapy Drum Circle Facilitation Homoeopathy Mind Colour o o o o Certified Spiritual Profile Consultant Drum Making Hypnofertility Mind Detox Method o o o o Chakra and Aura Therapy Eginton Alignment: Somatic Movement Hypnotherapy Mindfulness (Children and Education & Therapy o Adolescents) o Chakra Balancing I-Ching Readings o Egyptian Emotional Clearing Technique o o Mindfulness-based approaches o Chakra Balance - Relax.Nurture.Inspire Ignite Your Spirit o EMF Balancing Technique o o Monocrom Light & Colour o Channelling IMI Maternity & Child Sleep o EMDR Eye Movement Desensitization Consultant o Moving Beyond Stress o Chi Kung & Reprocessing o Infant and Child Sleep Consultant o Music Therapy o Childrens Wellbeing Courses o Emotional Rescue® o Ink Brush Painting o Myers Briggs Type Indicator o Chinese Herbal Medicine o Emotionally Focused Therapy o Inamojo Device o Chinese Nutrition o o Energetic/ Energy Healing o Inner Space Interactive Sourcing Native American Indian o CVT Crystal Vibrational Therapy o Energy Alignment Method (ISIS) Drumming o o Cytology o Energy Medicine o Integrated Bio-Dynamics Natural Spiritual Healing o o Chiron Healing o Eq4/Listen/Orion Assessment o Intergrated Self Empowerment Nature Based Therapy o o Clairvoyants o Ergonomics Therapy Neuro Linguistic Programming o (NLP) o Coffee/ Tea reading o Esoteric Healing (Spiritual Healing) Integrated Life Process o o Nitaai Breathing o Colour Therapy o Essence Of Angels Integrated Healing o o o Coral Essences o Essences of the Ancient Civilisations Integrated Therapeutic Alignment (ITA) Energy Medicine o Nutrition o Core Energetics o Estalt Therapy (Voice Dialogue) o Internal Fitness o Nutrition for Cats and Dogs o Core Energetix System o Eurythmy Therapy o Introspective Hypnosis o Nutrition for Horses o Core Energy Cleansing o Expressive Therapies o Intuitive Card Reading o Nutritional Therapies o Cosmos Child o Extended DISC System ‡ o Intuitive Counselling o Oneness o Cranial Electronics Point Holding o Eye Movement Desensutusatuib o Intuitive Dynamix o Oracle Card Reading o Crystal Awakening-Rachelle Charman & Reprocessing (EDRM) o Intuitive Healer & o Orb of Life o Crystal Dreaming™ o Face Readings Life Purpose Activator o Original 7 Level System of o Crystal Energy Healing o Facial Diagnostics ‡ o Jungian Analysis o Orion /EQ4/Listen Assessment o Crystal Light Bed Therapy o Facial Harmony o Karakia o Orion Healing Technique o Crystal Light Healing o o Kryslantium Healing o OSHO Meditation Instruction o Crystal O Therapy (Crystal Awareness) o Figure Diagnosis o Labyrinth Facilitation o OSHO Multiversity Modalities o Crystal Power Healing o Flame Tree o Life Field Therapy (LFT) o OSHO Neo-Reiki o Crystal Remote Viewing o Flower Essence Therapy o Life Sparkle o o Crystal Resonance Healing o Flower Reading

Administered by Lockton Affinity, LLC IICT Individual Application 6-2017 GROUP 3 CONTINUED: Base premium $193 o Palm Energy Reading o Quantum Healing Hypnosis o Sekham o The Emotional Code o Parapsychology o Therapy (QHHT) o Serenity Neuromeditation o The En- Method o Parent-Child Mother Goose o Quantum Stress and Trauma o Serenity Vibration Healing & o The Golden Ray Initiations Program Facilitator Release Enlightenment o The Inner Compass® o o o Parent-Child Mother Goose Quantum Healing Hypnosis Therapy Shamanic Bodywork o The Journey Program Facilitator Trainer o o Quantum Photo Somatics Shamanic Healing o The Kuan Yin Transmission o Past Life Healer o o Quantum Vortex Shamanic Studies o The Mace Energy Method o Past Life Regression (Therapy) o o Quit Cigarettes in 60 Minutes Shamanism and o The Pendulum o Past, Parrallel, Future Life o Transformational Mask QXCI Assessment o The Trust Technique Therapy (PPFLT) o o Rachelle Charman’s Crystal Shell Essences o o The Work of Byron Katie Pasture Management Awakening o Shi Liao o o Therapeutic Touch Path of Love o Rachelle Charman’s Crystal o Shifting Gears® o o Thermology Peak States Therapy Shamanism o Sleep Therapy o o o Theta Healing Pellowah Healings Radical Forgiveness o Somatic Integration Therapy o o o Thought Field Therapy (TFT) Phenolics Rainbow Motion TM o Somatic Therapy o o o Time Line Therapy Rapid Transformational Therapy o Somato Emotional Release o o o ToddlerCalm™ Plant Spirit Medicine Reconnective Healing o SoulLife Therapy™ o o o Tomatis Method Polarity Therapy Red Tent Circle Facilitator o Soul Focused Psychotherapy o o o Transcendental Meditation Power of Sound Reference Point Therapy o Soul Guidance and Sacred o Pranic Healing o Rebirthing Mentoring o Trimetrix EQ o Precognitive Therapy o Regression Therapy o Soul Regression Therapy o Tuning of Cells (previously Souls purpose) o Rekindled Ancient Wisdom o Sound Healing o Unconditional Love Healing o PrimalSoul Dance Meditation o Relax Kids o Space Clearing o Vastu Shastra o Prime Tuning Of Cells o Relaxation Breathing o Spinal Flow Breathwork o Vibemed Balance o Primus Activation Technique o Resonance Repatterning o Spiritual Artist o Vibralite o Prismology o Rewilding o Spiritual Empowerment o Vibrational Breath Therapy o Provision of Antenatal & o Rhythmic Movement Trainign o Spiritual Healing o Vibrational Medicine Postnatal - (Education Only) International (RMTI) o Spiritual Knowledge & o Vibrational Oneness o PSH Therapy o Rising Star Healing System Philosophy o Wellpoint Hypnosis o Psychic Artist o Runes o Spiritual Mentorship Method Practitioner o Psychics o Ryodoraku Assessment o Sports Training (remedial/ o Whole Hearted Healing o PSYCH-K® o Sacred Kurradji Science & Wisdom nutrition, not fitness) o Womb Awakening and Integrative o o Womb Hara Therapy Psychometry o Sacred Womb Awakening Starflower’s Spiritual o o o Zenith Omega Psychophysical Healing o Samassati Colour Light Therapy Systemic/Family Constellations o o o ZPoint Process, The Pure Wonder o Scerology Tarot Card Readings o o Qi Gong o Seichim Healing The Body Code o o Quadeucous o Self Mastery Techniques The Dermafield

GROUP 4: Base premium $220 o Acrylic Nails ‡ o Airbrush Makeup ‡ o Animal Osteopathy - Dogs & o Baby o Action Potential Stimulation o Akupunkt Massage Horses o Baby Rocks Therapy (APS) † o Applied Lingua-physiology o Algotherapy ‡ o Balneotherapy ‡ o o Active Release Technique o Alpha RePatterning AromaTouch™ Technique o o o Acupressure o Allergy Testing Asian Bio-Energy Therapy o Beauty Therapists o o Advanced Skin Care o Animal Healing Attractor Field Therapy o B.E.ST. (Bio-Energetic o o Advanced Clinical Weight Loss o Animal Auro-Kinetic Training Synchronisation System) Practitioner o o o Animal Myo-manipulative Best System Assessment o Advanced Dietary Functional Therapy o Ayurvedic Kansa Wand Facelift o Bindi Bodywork ‡ Supplements Advisor Massage Administered by Lockton Affinity, LLC IICT Individual Application 6-2017 GROUP 4 CONTINUED: Base premium $220 o Bio Energy Detox Foot Spa o Compression Wrap o Esogetic Colourpuncture o Hydrotherapy o Bio Lifting ‡ o Counselling - Financial (other than o Esoteric Chakra Puncture o IFAS High Frequency Electrical work requiring fin serv. lic.) Treatment ‡ o Bio Magnetic Synchronisation o Facial Hair Removal - Threading ‡ Technique BMS o CPT Complex Physical Therapy o Indian Head Massage o Facial Hair Removal - Tweezing ‡ o Biomagnetism (Medical o Craniosacral Therapy o Infra Red Therapy o Fascial Kinetics or Biomagnetic Pairs Therapy) o Cross Fibre Mobilisation o Infrared Body Wrap o Facials ‡ o Birth Rocks o Cycloid Vibration Therapy o Integral Energetics o Fango Body Treatment o Bloodscan o Cupping o Integrated Therapeutic Alignment o Faradism o Body Scrub ‡ o Daavid Therapy (ITA) Energy Medicine o Feather Wand o Body Wrap o DamselFly Transformative Healing o Intense Pulsed Light IPL o Feldenkrais o Bodyflow Machine o Darkfield (live blood o Interior Alignment o FIR Blanket † o Bowen Therapy analysis) o Interlinked Healing Technique o Financial Counselling o Bowen Therapy on Animals o Deep Penetrating Light Therapy o Ionic Foot bath (Mary Staggs o Finch Therapy o Buteyko o Denas Therapy Detox) o Fingernails - Acrylic Fingernails ‡ o o Canine Myofunctional Therapy o Di Morrow Method o Fit Genes DNA Profiling o o Canine Rehabilitation o Dietitian James Method for Asthma o First Aid facilitator o o Canine Touch o Doula (including light domestic duties) Jin Shin Jyustu® o Floatation tank o o Cat and Canine Muscle Release o Dry Needling Joint Anchor Technique o Foot and Hand Care Therapy (CCMRT) ‡ o Electrical Stimulation (eg TENS) o Kahuna Bodywork o o Foot Care Cathiodermie † o Electro-dermal Screening o Kanetica™ Structural Balancing o o Forensic Healing Certified Detox Specialist o Electrology ‡ (shortwave, diathermy o Karuna Reiki o ChakraDance and blend) o Functional Integration Awareness o Ka-Tone Deep Tissue o Chakra (energy massage) o Electrolysis o Functional Medicine Health Coach o Kinergetics o Chavutti Thirumal ‡ o Electroregenesis o Function Fascial Taping o Kinesiology o Chi Reflexology o Emmett Technique o Galvanism o Kyda Muscle Therapy o Champissage o Emmett Technique on Animals o Gas Discharge Visualisation o Lactation Consulting (GDV) Camera o Chi Nei Tsang o Emotional Freedom Technique o Lava Shell Massage o Gel Nails ‡ o Chinese Acupressure o ENAR Device o Life Alignment o Genetic Counselling ‡ o Cleopatra Skin Advanced o ENAR Therapy o Live Blood Analysis ‡ o Gerontology ‡ o Quantum Healing o Endermology o Loofah Scrub o Glycolic Facial ‡ o Cleopatra Skin Back Relief Yoga o Epidermabrasion o Looyen Work o Gommage o Cleopatra Skin Face Lift Yoga o Equine and Canine Rehabilitation o Low Level Laser Therapy ‡ and Training o Halo Therapy ‡ o Cleopatra Skin Natural Face o Magnetic Therapy Lift Massage o Equine Body Therapy o Hatchards Way o Magnified Healing o Cleopatra Skin Natural o Equine Hoof Care o Healing Touch Practitioner o Makeup ‡ Family Healing o Equine Muscle Release Therapy o Healy Wellness Consultant o Manicures ‡ o Cleopatra Skin Hot Spot Body Rock (EMRT) o H.E.C. Remedial therapy o Manual Lymphatic Drainage o Cleopatra Skin Quantum Healing o Equine Myofunctional Therapy o Heller Work o Mary Staggs Foot Detox o Cleopatra Skin Tummy Tuck Yoga o Equine o Hemaview (Live Blood Analysis) o Mask and Traditional Healing o Cleopatra Skin Voice and Sound o Equine Photonic Therapy o Herbal Medicine for Dogs & Cats o McLoughlin Scar Tissue Healing o Equine Podio-Therapy o Herbal Medicine for Horses Release Technique o Cleopatra Wrinkle Reduction o Equine Positional Release o Herbalism/ Herbal Medicine Massage o Medical Intuition o Equine Raindrop Technique o Holistic Pulsing o Clinical Camouflage Make-up o Meridian Psychotherapy o Equine Salt Therapy o Homotoxicology o Clinical Laser Therapy (non thermal) o Metamorphic o Equine o Horstmann Technique o Collagen Facial o Metatronic Energy o Equine Touch o Hoshino Therapy o Complex Lymphatic Drainage o Micro Current o Equinology o Hot Stone Therapy o Complex Lymphatic Therapy o Microdermabrasion ‡ o Equus Muscle Management o Hydration Facial o Mind Energetix

Administered by Lockton Affinity, LLC IICT Individual Application 6-2017 GROUP 4 CONTINUED: Base premium $220 o Mora Therapy o Pedicures † o Seaweed Wrap ‡ o Trigger Point Therapy o Mud treatment ‡ o Photonic Therapy o Shen Therapy o Tuning Fork o Therapy o Phototherapy o Shiatsu o Ultra Sonic o Myofascial Release Therapy for o Physiotherapist o SimplyHealed Method o Universal Contour Wrap Horses & Dogs o Point of Care (live blood analysis) o Slimtronic Body Toning o Vega Testing (Allergy Testing) o Myotherapy - excluding Dry o o SLM Bodywork o Vibrational Kinesiology Needling o Pre & Post Natal Therapy † o Sports Therapy o Vibrosaun o NAET (Nambudripads Allergy Elimination Technique) o Psychosamatic Therapy o Spray Tanning ‡ o Viceral Manipulation (excluding spinal manip.) o Natural Vision Improvement o Pulsed Electro Magnetic o Steam Sauna Field Therapy o Virbomuscular o o Structural Integration Naturopathy Harmonization Technique o Quantum BioEnergetics o o Structural Kinesiology Neuro Muscular Transmission o Vita Flex Technique o Quantum Soul Healing Integration o o (SKART) Acupressure Release Neuro Psychological Immunity & o Vocational Rehabilitation Vibrational medicine o Quantum Touch Technique o Vodder Technique Man. o o Rahzay o Sunbeds and Solariums Neuro Skeletal Therapy Lymph. Drainage. o o Raindrop Technique® o Swiss Ball Neuro Structural Integration o Watsu o o Raynor Technique o Synergistic Kinesiology Neurodevelopmental Therapy o Weight Management o o Recreation Therapy o Tapas Acupressure Neuromodulation Technique o Weightloss Consultant † Technique - (TAT) o o Reflexology Neuro-Training o Whole Energy Body Balance o TAT for Weight Loss o Niblett Technique o Reichian Massage for Animals Energywork o TENS Machine o NST Equine o Reiki o Wellness-Spa Practitioner o Thalasso Therapy o Nutritional Therapist o Reiki on Animals (IAM Academy) o The Arvigo Techniques of Maya o o O2 Detox foot bath o RESET (Kinergetics) Whole Energy Body Balance Abdominal Therapy for Pets Bodywork o O2 Detox Spa o Rhythmic Movement Training International (RMTi) o The Footprint Connection o Zentai Therapy o Occupational Health, Safety o The Masterson Method o & Ergonomics o o The Spiral o Occupational Therapy o Rosen Method Bodywork o Thermal Therapy o Oceanic Body Work o Rotai Pain Relief (Aust) o Tibetan Pulsing o Onsen Technique o Salt Scrub ‡ o Touch for Health o Ortho-Bionomy o Salt Therapy ‡ o Traditional Chinese Medicine o Orthoptics o Sanctum MindSpa o Transpersonal o OSHO Craniosacral o Scenar Therapy for Small Animals o Traditional Eastern Cupping o OSHO Rebalancing o Scenar Professional Device o Trichology o Paraffin treatment o Sea Clay Body Wrap ‡

Section V: ADDITIONAL INSUREDS TO BE INSURED (Additional Insured Coverage is subject to a valid insurable interest and written requirement for coverage of the Additional Insured on your insurance) Describe the business relationship/insurable interest of Additional Insured to you from the list below.* Business Relationship/Insurable Interest: Name of Additional Insured Complete Address of Additional Insured (enter the applicable number (s) from the list provided below or explain)

(1) Co-Owner Of Insured Premises (2) Grantor Of Franchise (3) Land Owner Lessor Of Leased Equipment Lessor of Premises (4) Managers of Premises used for providing Professional Services (5) Mortgagee, Assignee, Or Receiver (6) Owner Or Other Interests From Whom Land Has Been Leased (7) I am in a contractual agreement with the requested Additional Insured to name them as such (8) They are my employee or independent contractor (9) Other; please describe.

Administered by Lockton Affinity, LLC IICT Individual Application 6-2017 Section VI: WARRANTY QUESTIONS (“You” means any individual proposed for this insurance including any current or past employee, independent contractor or additional insured on your behalf.)

1. Within the last 10 years, have you ever had any of the following revoked, suspended, refused, denied renewal, cancelled, placed on probation, voluntarily surrendered or is such pending? a) State license, certification or registration o Yes o No b) Malpractice insurance o Yes o No 2. Within the last 10 years, has a claim or suit for alleged malpractice been brought against you or are you aware of any incident o Yes o No that might reasonably lead to such a claim or suit?

3. Have you ever been convicted (as an adult) of a felony or is any such case pending? o Yes o No 4. Within the last 10 years, have you had any complaints or charges brought against you by any licensing board or professional ethics body? o Yes o No

IMPORTANT: If any answer above is “Yes”, please attach a detailed explanation including dates, names of parties involved, allegations, your written response to the allegations if applicable and a copy of any formal ruling or notice by any regulator, licensing body, professional ethics board or insurer.

Section VII: SIGNATURE / DATE

I hereby declare that the preceding statements and particulars contained in this application are true and that I have not suppressed or misstated any material facts and I agree that this declaration shall be the basis of the contract between me and the underwriters. SIGNING THIS FORM OR SUBMISSION OF PAYMENT DOES NOT BIND THE APPLICANT OR UNDERWRITER TO COMPLETE THE INSURANCE. HOWEVER, IF COVERAGE IS BOUND, THIS APPLICATION BECOMES A PART OF THE POLICY.

PLEASE TAKE NOTICE THAT:

1. Lockton may receive compensation from an insurer or other intermediary as a result of the sale of insurance to you. 2. The compensation received by Lockton may differ depending on the product, insurer and/or other intermediary. 3. Lockton may receive additional compensation from the insurer and/or other intermediary based upon other factors, such as premium volume placed with a particular insurer or through a particular intermediary and loss or claims experience.

I request that my insurance become effective on: ______/ ______/ ______(Effective date may not be earlier than the date the application is received by the administrator and not more than 45 days from the date of this application.)

Signature Date

Questions? Website: www.locktonmedicalliabilityinsurance.com | Email: [email protected] Phone: (800) 253-5486 | Fax: (913) 652-3966

This Professional Liability Insurance program has been organized as a purchasing group (National Professional Purchasing Group Association, Inc.), pursuant to legislation enacted by the U.S. Congress as the Federal Liability Risk Retention Act of 1986. You automatically become a member of the purchasing group once your completed application has been approved and your premium has been received. LII 482 A (07/13)

Administered by Lockton Affinity, LLC IICT Individual Application 6-2017