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

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

Coverage Indicate which individual activities for which coverage is requested.

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

Administered by Lockton Affinity, LLC IICT Individual Application 6-2017 GROUP 1 COUNTINUED: Base premium $117 o Pyschophysics o Therapies o Telephone Counselling † o Quantum Emotional Healing™ o Soul Link o Transpersonal Art Therapy o Restoration o Speech Pathology † o Transpersonal Counselling o Sacred Circles o Spiritual Counselling o The Sister Circles Facilitator o Sandplay o Stress Management † o The Joyality Program

GROUP 2: Base premium $178

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

GROUP 3: Base premium $193 o Access Conciousness (Access Bars) o Animal Dreaming o Autogenic Training o Body Electronics Point Holding o Access Bars o Animal Training - Dogs & Cats o Avatar Assessment o Body Mind Resolution (BMR) Healing o Access EFT o Anthroposophy (spiritual philosophy) o BabyCalm™ o Body Network & Beyond o Accusense 232 Assessment o Aqua Detox o Bach Flower Remedies o Body Psychotherapy o Accusonic Plus Ultrasound Machine o Aqua Detox Medical Unit o Bicom Instrument o Body Stress Release o Acu-energetics o Aquarian Healing o Biodanza o Body Talk Systems o Acutonics o Aquatic Bodywork o Bio Energetics Medicine o Brain Gym o Advanced Sports & Exercise o Arolo o Bio Feedback o Brainwave Optimisation® Nutritional Advisor o Arolo Tifar o Biograph Assessment o Breathwork o African Drumming o AromaBliss o Bioimpedance Analysis o Breathworks Mindfulness o Aka Lani o Aromatherapy o Birth Skills™ o Brennan Healing o Alexander Technique o Aromatherapy (Flower Essences) o Body Acceptance & appreciation o Bush Flowers o Allergy Kit Allergy Relief Treatments o Aromatherapy on Horses for women † o California Flowers o o Angel Card Reading o Aromatic Medicine Body Acceptance & appreciation o Calmbirth® † o for youth † Angelic Healing o Ashati o Celluloid Mineral therapy o o Body Love Intuitive Angel Intuitive o Aston Patterning o Chakra and Aura Therapy o o Bioresonance Therapy Angel Therapy Practitioner o Astrology (incl. Chinese Astrology) o Chakra Balancing o o Biosenetics Animal B.E.S.T. (Bio-Energetic o Asyra Device o Chakra Balance - Relax.Nurture.Inspire Synchronziation Technique) o Body Connect Healing o Audio Sound o Channelling o Animal Communication o Body Composition Test ‡ o Aura-Soma® o Chi Kung

Administered by Lockton Affinity, LLC IICT Individual Application 6-2017 GROUP 3 CONTINUED: Base premium $193 o Chinese Herbal Medicine o Emotionally Focused Therapy o Inamojo o Numerology o Chinese Nutrition o Energetic/ Energy Healing o Inner Space Interactive Sourcing o Nutrition (ISIS) o CVT Crystal Vibrational Therapy o Energy Alignment Method o Nutrition for Cats and Dogs o Integrated Bio-Dynamics o Cytology o Energy Medicine o Nutrition for Horses o Intergrated Self Empowerment o Chiron Healing o Eq4/Listen/Orion Assessment o Nutritional Therapies Therapy o Clairvoyants o Ergonomics o Oneness o Integrated Life Process o Coffee/ Tea reading o Esoteric Healing (Spiritual Healing) o Oracle Card Reading o Integrated Healing o Colour Therapy o Essence Of Angels o Orb of Life o Internal Fitness o Coral Essences o Essences of the Ancient Civilisations o Original 7 Level System of Reiki o Introspective Hypnosis o Core Energetics o Estalt Therapy (Voice Dialogue) o Orion /EQ4/Listen Assessment o Intuitive Card Reading o Core Energetix System o Eurythmy Therapy o Orion Healing Technique o Intuitive Counselling o Core Energy Cleansing o Expressive Therapies o OSHO Meditation Instruction o Intuitive Dynamix o Cosmos Child o Extended DISC System ‡ o OSHO Multiversity Modalities o Jungian Analysis o Cranial Electronics Point Holding o Eye Movement Desensutusatuib o OSHO Neo-Reiki o & Reprocessing (EDRM) Karakia o Crystal Awakening-Rachelle Charman o Palmistry o o Face Readings Kryslantium Healing o Crystal Dreaming™ o Palm Energy Reading o o Facial Diagnostics ‡ Labyrinth Facilitation o Crystal Energy Healing o Parapsychology o o Facial Harmony Life Field Therapy (LFT) o Crystal Light Bed Therapy o Parent-Child Mother Goose o o Life Sparkle o Crystal Light Healing Feng Shui Program Facilitator o o Lifeline Technique *† o o Crystal O Therapy (Crystal Awareness) Figure Diagnosis Parent-Child Mother Goose o o Lightworker Practitioner Program Facilitator Trainer o Crystal Power Healing Flame Tree o o Listen/EQ4/Orion Assessment o Past Life Healer o Crystal Remote Viewing Flower Essence Therapy o o Living Authentically® o Past Life Regression (Therapy) o Crystal Resonance Healing Flower Reading o o o Free to Be Me Living Love Past, Parrallel, Future Life o Crystal Shamanism-Rachelle Charman Therapy (PPFLT) o o Mace Energy Method o Crystal Sound Therapy Functional Diagnostic Nutrition o o Pasture Management o Gem Essences Magnetabiology o Crystal Therapy o Path of Love o o Manifestation Coaching o Demartini Method Geomancy o o Peak States Therapy o Gestalt Therapy Meditation o Diamond Light Practitioner o Pellowah Healings o o Mediums / Channeling o Direction Technique Hahnemann Healing o o Phenolics o Hakomi Meet Yourself Therapy o Didgeree Doo Sound Healing o Phrenology o o Meliae Intuitive Healing o Dietary Consultant (Nutritional Heal Your Life o o Plant Spirit Medicine Counselling) o Heart Energetics Metatronia Therapy® o o Polarity Therapy o Diversional Therapy o HeartMath Mickel Therapy o o Power of Sound o Divine Source Enhancement Healing o Heart Resonance Therapy Mind Colour o o Pranic Healing o DLF Therapy o Hexagram of Balance Mind Detox Method o o Precognitive Therapy o Down Size Me Food Coaching o Holistic Energy Care Mindfulness (Children and Adolescents) (previously Souls purpose) o Dowsing (Energy Healing only) o Holistic Healing o o Mindfulness-based approaches PrimalSoul Dance Meditation o Dream Work/Interpretation o Holographic Repatterning / o o Monocrom Light & Colour Prime Tuning Of Cells o Drum Circle Facilitation Resonance Repatterning o o Primus Activation Technique o Homoeopathy Moving Beyond Stress o Drum Making o Prismology o o Music Therapy o Eginton Alignment: Somatic Movement Hypnofertility o o Provision of Antenatal & Education & Therapy o Hypnotherapy Myers Briggs Type Indicator Device Postnatal - (Education Only) o Egyptian Emotional Clearing Technique o I-Ching Readings o o Native American Indian Drumming PSH Therapy o EMF Balancing Technique o Ignite Your Spirit o o Natural Spiritual Healing Psychic Artist o EMDR Eye Movement Desensitization o IMI Maternity & Child Sleep o o Psychics & Reprocessing Consultant Neuro Linguistic Programming (NLP) o PSYCH-K® o Emotional Rescue® o Ink Brush Painting o Nitaai Breathing o Psychometry

Administered by Lockton Affinity, LLC IICT Individual Application 6-2017 GROUP 3 CONTINUED: Base premium $193 o Psychophysical Healing o Rhythmic Movement Trainign o SoulLife Therapy™ o The Trust Technique o Qi Gong International (RMTI) o Soul Focused Psychotherapy o The Work of Byron Katie o o Quantum Healing Hypnosis Rising Star Healing System o Soul Guidance and Sacred o Therapeutic Touch o o Therapy (QHHT) Runes Mentoring o Thermology o o o Quantum Stress and Trauma Ryodoraku Assessment Soul Regression Therapy o Theta Healing o o Release Sacred Kurradji Science & Wisdom Sound Healing o Thought Field Therapy (TFT) o o o Quantum Healing Hypnosis Therapy Sacred Womb Awakening Space Clearing o Time Line Therapy o o o Quantum Vortex Samassati Colour Light Therapy Spiritual Artist o ToddlerCalm™ o o o Quit Cigarettes in 60 Minutes Scerology Spiritual Empowerment o Tomatis Method o o o QXCI Assessment Seichim Healing Spiritual Healing o Transcendental Meditation o o o Rachelle Charman’s Crystal Sekham Spiritual Knowledge & o Trimetrix EQ Awakening o Philosophy Serenity Neuromeditation o Tuning of Cells o Rachelle Charman’s Crystal o o Sports Training (remedial/ Serenity Vibration Healing & o Unconditional Love Healing Shamanism Enlightenment nutrition, not fitness) o o o Vastu Shastra Radical Forgiveness o Shamanic Bodywork Starflower’s Spiritual Alchemy o o o Vibemed Balance Rapid Transformational Therapy o Shamanic Healing Systemic Constellations o o o Vibralite Reconnective Healing o Shamanic Studies Tarot Card Readings o o o Vibrational Breath Therapy Red Tent Circle Facilitator o Shamanism and The Body Code o Reference Point Therapy Transformational Mask o The Dermafield o Vibrational Medicine o Rebirthing o Shell Essences o The Emotional Code o Vibrational Oneness o Regression Therapy o Shi Liao o The En-Orgone Method o Wellpoint Hypnosis Method Practitioner o Rekindled Ancient Wisdom o Shifting Gears® o The Golden Ray Initiations o Whole Hearted Healing o Relax Kids o Sleep Therapy o The Inner Compass® o Zenith Omega o Relaxation Breathing o Somatic Integration Therapy o The Journey o ZPoint Process, The o Resonance Repatterning o Somatic Therapy o The Mace Energy Method o Rewilding o Somato Emotional Release o The Pendulum

GROUP 4: Base premium $220 o Acrylic Nails ‡ o Auro-Kinetic Training o Body Wrap o Quantum Healing o Action Potential Stimulation o Ayurveda o Bodyflow Machine o Cleopatra Skin Back Relief Yoga Therapy (APS) † o Baby Reflexology o Bowen Therapy o Cleopatra Skin Face Lift Yoga o Active Release Technique o Baby Rocks o Bowen Therapy on Animals o Cleopatra Skin Natural Face o Acupressure o Balneotherapy ‡ o Buteyko Lift Massage o Advanced Skin Care o o Bates Method o Canine Myofunctional Therapy Cleopatra Skin Natural o Advanced Clinical Weight Loss Family Healing o Beauty Therapists o Canine Rehabilitation Practitioner o Cleopatra Skin Hot Spot Body Rock o B.E.ST. (Bio-Energetic o Canine Touch o Advanced Dietary o Cleopatra Skin Quantum Healing Synchronisation System) o Cat and Canine Muscle Release Supplements Advisor o o Best System Assessment Therapy (CCMRT) ‡ Cleopatra Skin Tummy Tuck Yoga o Airbrush Makeup ‡ o o Bindi Bodywork ‡ o Cathiodermie † Cleopatra Skin Voice and Sound o Akupunkt Massage Healing o Bio Energy Detox Foot Spa o Certified Detox Specialist o Algotherapy ‡ o Cleopatra Wrinkle Reduction o Bio Lifting ‡ o ChakraDance o Allergy Testing Massage o Bio Magnetic Synchronisation o Chakra (energy massage) o Animal Healing o Clinical Camouflage Make-up Technique BMS o Chavutti Thirumal ‡ o Animal Homeopathy o Clinical Laser Therapy (non thermal) o Biomagnetism (Medical o Chi Reflexology o o Animal Osteopathy - Dogs & Horses or Biomagnetic Pairs Therapy) Collagen Facial o Champissage o o Applied Lingua-physiology o Birth Rocks Complex Lymphatic Drainage o Chi Nei Tsang o o AromaTouch™ Technique o Bloodscan Complex Lymphatic Therapy o Chinese Acupressure o o Attractor Field Therapy o Body Scrub ‡ Compression Wrap o Cleopatra Skin Advanced Administered by Lockton Affinity, LLC IICT Individual Application 6-2017 GROUP 4 CONTINUED: Base premium $220

o Counselling - Financial (other than o Facial Hair Removal - Threading ‡ o Indian Head Massage o Myotherapy - excluding Dry work requiring fin serv. lic.) Needling o Facial Hair Removal - Tweezing ‡ o Infra Red Therapy o CPT Complex Physical Therapy o NAET (Nambudripads Allergy o Fascial Kinetics o Infrared Body Wrap o Craniosacral Therapy Elimination Technique) o Facials ‡ o Integral Energetics o o Cross Fibre Mobilisation Natural Vision Improvement o Fango Body Treatment o Intense Pulsed Light IPL o o Cycloid Vibration Therapy Naturopathy o Faradism o Interior Alignment o o Cupping Neuro Muscular Transmission o Feather Wand o Interlinked Healing Technique o Neuro Psychological Immunity & o Daavid Therapy o Feldenkrais o Ionic Foot bath (Mary Staggs Detox) Vibrational medicine o DamselFly Transformative Healing o FIR Blanket † o Iridology o Neuro Skeletal Therapy o Darkfield Microscopy (live blood o Financial Counselling o James Method for Asthma o analysis) Neuro Structural Integration o Finch Therapy o Jin Shin Jyustu® o o Deep Penetrating Light Therapy Neurodevelopmental Therapy o Fingernails - Acrylic Fingernails ‡ o Joint Anchor Technique o o Denas Therapy Neuromodulation Technique o Fit Genes DNA Profiling o Kahuna Bodywork o o Di Morrow Method Neuro-Training o First Aid facilitator o Kanetica™ Structural Balancing o o Dietitian Niblett Technique o Floatation tank o Karuna Reiki o o Doula (including light domestic duties) NST Equine o Foot and Hand Care o Ka-Tone Deep Tissue o o Dry Needling Nutritional Therapist o Foot Care o Kinergetics o o Electrical Stimulation (eg TENS) O2 Detox foot bath o Forensic Healing o Kinesiology o o Electro-dermal Screening O2 Detox Spa o Functional Integration Awareness o Kyda Muscle Therapy o o Electrology ‡ (shortwave, diathermy Occupational Health, Safety and blend) o Functional Medicine Health Coach o Lactation Consulting & Ergonomics o o Electrolysis o Function Fascial Taping o Lava Shell Massage Occupational Therapy o o Electroregenesis o Galvanism o Life Alignment Oceanic Body Work o o Emmett Technique o Gas Discharge Visualisation o Live Blood Analysis ‡ Onsen Technique (GDV) Camera o o Emmett Technique on Animals o Loofah Scrub Ortho-Bionomy o Gel Nails ‡ o o Emotional Freedom Technique o Looyen Work Orthoptics o Genetic Counselling ‡ o o ENAR Device o Low Level Laser Therapy ‡ OSHO Craniosacral o Gerontology ‡ o o ENAR Therapy o Magnetic Therapy OSHO Rebalancing o Glycolic Facial ‡ o o Endermology o Magnified Healing Paraffin treatment o Gommage o o Epidermabrasion o Makeup ‡ Pedicures † o Halo Therapy ‡ o o Equine and Canine Rehabilitation o Manicures ‡ Photonic Therapy o Hatchards Way and Training o Manual Lymphatic Drainage o Phototherapy o Healing Touch Practitioner o Equine Body Therapy o Mary Staggs Foot Detox o Physiotherapist o H.E.C. Remedial therapy o Equine Hoof Care o Mask and Traditional Healing o Point of Care (live blood analysis) o Heller Work o Equine Muscle Release Therapy o McLoughlin Scar Tissue o Postural Integration (EMRT) o Hemaview (Live Blood Analysis) Release Technique o Pre & Post Natal Therapy † o Equine Myofunctional Therapy o Herbal Medicine for Dogs & Cats o Medical Intuition o Psychosamatic Therapy o Equine Naturopathy o Herbal Medicine for Horses o Meridian Psychotherapy o Quantum BioEnergetics o Equine Photonic Therapy o Herbalism/ Herbal Medicine o Metamorphic o Quantum Soul Healing Integration o Equine Podio-Therapy o Holistic Pulsing o Metatronic Energy o Quantum Touch o Equine Raindrop Technique o Homotoxicology o Micro Current o Rahzay o Equine Salt Therapy o Horstmann Technique o Microdermabrasion ‡ o Raindrop Technique® o Equine Shiatsu o Hoshino Therapy o Mind Energetix o Raynor Technique o Equine Touch o Hot Stone Therapy o Mora Therapy o Recreation Therapy o Equinology o Hydration Facial o Mud treatment ‡ o Reflexology o Equus Muscle Management o Hydrotherapy o Myofascial Release Therapy o Reichian Massage o Esogetic Colourpuncture o IFAS High Frequency Electrical o Myofascial Release Therapy for o Reiki o Esoteric Chakra Puncture Treatment ‡ Horses & Dogs o Reiki on Animals

Administered by Lockton Affinity, LLC IICT Individual Application 6-2017 GROUP 4 CONTINUED: Base premium $220 o RESET (Kinergetics) o Sports Therapy Abdominal Therapy o Vibrosaun o Rolfing o Spray Tanning ‡ o The Masterson Method o Viceral Manipulation o Rosen Method Bodywork o Steam Sauna o Thermal Therapy (excluding spinal manip.) o o Rotai Pain Relief (Aust) o Structural Integration o Tibetan Pulsing Virbomuscular Harmonization Technique o Salt Scrub ‡ o Structural Kinesiology o Touch for Health o Vita Flex Technique o Salt Therapy ‡ o Acupressure Release o Traditional Chinese Medicine o Vocational Rehabilitation o Sanctum MindSpa Technique (SKART) o Transpersonal Crystal Healing o o Sunbeds and Solariums Vodder Technique Man. o Scenar Therapy for Small Animals o Traditional Eastern Cupping Lymph. Drainage. o Swiss Ball o Scenar Professional Device o Trichology o Watsu o Synergistic Kinesiology o Sea Clay Body Wrap ‡ o Trigger Point Therapy o Weight Management o Tapas Acupressure o Seaweed Wrap ‡ o Tuning Fork o Technique - (TAT) Weightloss Consultant † o Shen Therapy o Ultra Sonic o o TAT for Weight Loss Zentai Therapy o Shiatsu o Universal Contour Wrap o o TENS Machine Zero Balancing o SimplyHealed Method o Vega Testing (Allergy Testing) o Thalasso Therapy o Slimtronic Body Toning o Vibrational Kinesiology o The Arvigo Techniques of Maya o SLM Bodywork

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.

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.

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