I. GENERAL INFORMATION:

A. Name and address of applicant:

Phone Number: Fax Number:

B. Executive Officer in Daily Management:
(Name) (Title)

C. Sole Proprietorship Corporation Partnership Year Business Began?

II. LOSS HISTORY:

A. Furnish loss history (3 years) for all claims alleging errors in the drug testing process.

B. Are you aware of any facts, incidents or circumstances which may result in claims being made against you under the proposed insurance policy? (If yes, please provide details on separate sheet) Yes No

C. Has the proposed coverage ever been purchased before, whether specifically or as part of another insurance contract? Yes No

D. Has any insurer ever canceled or non-renewed this type of coverage? (If yes, please provide details on separate sheet) YesNo

E. Have you or any of your employees ever been the subject of disciplinary or investigative proceedings or reprimanded by an administrative or governmental agency, hospital or professional association? (If yes, please provide details on separate sheet) Yes No

F. Are you currently a member of:
Drug & Alcohol Testing Industry Association Yes No

G. Provide the following information for any similar insurance, if any, carried during the last three years.

III. EMPLOYEES:

Number of employees: Full Time: Part Time:

IV. SCOPE OF BUSINESS SERVICES:

Please answer the following and also attach your current service description brochures.
In the first box type "YES" or "NO." If yes, enter % of Clients' Total Tests in the second box.

Do you perform any or all of the following services?
(If you provide some, but not all of the services, please explain on an attached sheet.)

As a Third Party Administrator/Facilitator:

(1) Obtaining, contracting with and managing collection sites, breath alcohol technicians, laboratories,
medical review officers (MRO).

(2) Do you or your employees actually perform any of the above listed services.
If so, which: CollectionLab TestsMedical Review

(3) Urinalysis or alcohol blind specimen quality assurance.

(4) Preparation of or consulting on company policies on substance abuse.

(5) Random testing administration.

(6) 24-hr post accident and reasonable cause testing administration.

(7) Other

V. TEST ADMINISTRATION (including TPA, Collection and MRO):

Please provide estimated testing count for the coming year for the following classes:

Further explanation:

VI. MEDICAL REVIEW OFFICER (for each associated MRO):

Name:

Address:

Employee: Independent: Accrediting Organization:

VII. LABORATORY:

Any person who knowingly and with Intent to defraud any Insurance company or another person files an application for insurance containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent Insurance act, which is a crime and subjects the person to criminal and civil penalties.

Date Applicant's Authorized Signature (Principal, Partner or Officer Title)