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FLEXI PLUS FIVE APPLICATION Instructions: Applicant

FLEXI plus five APPLICATION NOT-FOR-PROFIT ORGANIZATION DIRECTORS AND OFFICERS LIABILITY INSURANCE EMPLOYMENT PRACTICES LIABILITY INSURANCE FIDUCIARY LIABILITY INSURANCE WORKPLACE VIOLENCE COVERAGE INTERNET LIABILITY INSURANCE THIS IS AN APPLICATION FOR A CLAIMS MADE POLICY PLEASE READ YOUR POLICY CAREFULLY Instructions: Whenever used in this APPLICATION the term Applicant shall mean the Parent Organization and its wholly-owned/controlled subsidiaries. The Applicant is required to complete Sections 1, 2, and 7. The Applicant should complete other applicable Section(s) for which coverage is desired.

PIIC-NPD-NEW APP (09/06) Page 4 of 9 3. Does any plan(s) employ the investment, trustee, actuarial, legal, administrative, custodial or benefits consulting

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