REQUEST TO INCREASE LIMITS OF LIABILITY

Note: An Increase in limit change will result in a change in premium. All policy changes are subject to Underwriting review and approval

CLAIMS MADE

Disclaimer Period

Retroactive Date

Year/Month/Day

Insured's First Name*

Insured's Last Name*

Policy Number*

Email*

I warrant that no claims(s), or request(s) for medical records have been brought against me as a result of any act or omission during the disclaimer period state above, other than as previously reported by me to the Company. Furthermore, I am unaware of any act or omission occurring during the disclaimer period stated above which might be expected to be the basis of a claim or suit brought against me in the future.*

Please increase my limits of liability to the following:

New limits of liability:*

Reason for Request:*

Proposed effective date of endorsement*

Note: The requested effective date for any increase in limits of liability is subject to Underwriting Department approval. We are unable to back date this request

Year/Month/Day

Name of managed care program requiring higher limits:*

Signature of Insured*

Date*

Year/Month/Day

"OUM" and "OUM Chiropractor Program" do not refer to a legal entity or insurance company but to a program or symbol of a program underwritten, insured and administered by ProAssurance Insurance Company of America. ProAssurance Group is rated “A” (Excellent) by A.M. Best.