REQUEST TO INCREASE LIMITS OF LIABILITY

Note: An increase in limits of liability will result in a change in premium. All policy changes are subject to Underwriting review and approval.

Disclaimer Period

If you have a Claims Made policy, please provide 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 stated 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