Insurance Security Sale Supplement

INSURANCE SECURITY SALE SUPPLEMENT

Insurer Name:    Applicant / Insured Name:

Policy Number:    Effective Date:    Supplement Date:

TRANSACTION DETAILS

Date of Sale:    Settlement Date:

CUSIP / ISIN:    Quantity / Shares:

Gross Sale Price (per lot/total):    Currency:

PROCEEDS, SETTLEMENT, AND ACCOUNTING

Proceeds Account (Financial Institution):

Account Number (last 4 digits):    Were proceeds deposited to an insured account? Yes No

Reinvestment into other securities    Debt repayment    Withdrawal to owner account    Other (describe below)

POLICY IMPACT & COVERAGE REQUEST

Current Coverage Type:    Coverage Amount:

Deductible:    Premium (current):

Increase coverage amount    Reduce coverage amount    Add endorsement for securities transfer risk

REPRESENTATIONS, WARRANTIES AND CERTIFICATIONS

The undersigned hereby represents and warrants to the Insurer that the facts set forth herein are true and complete to the best of the Applicant's knowledge. The Applicant certifies that at the time of sale the Applicant had lawful title or appropriate authority to sell or transfer the securities described above. The Applicant further certifies:

No claim or potential claim related to the described securities or transaction is pending or known: Yes No

There has been no material misstatement, omission, or concealment of facts related to the securities or transaction that would affect risk selection or premium: Yes No

EXCLUSIONS AND ENDORSEMENTS

The Insurer's standard exclusions applicable to this supplement include, but are not limited to: market loss, diminution in value due to market fluctuation, consequential damages, and losses arising from fraudulent concealment by non-disclosed third parties. Any change to exclusions or the issuance of endorsements will be recorded as a formal endorsement to the policy.

Endorsements requested (check all that apply): Transfer of risk endorsement    Proceeds coverage endorsement    Other (describe below)

BENEFICIARY / LOSS PAYEE

Relationship:    Allocation Percentage:

DOCUMENTATION CHECKLIST

Attachments submitted with this supplement (check all provided): Trade confirmation    Settlement statement (STP/TT)    Broker invoice    Securities certificate or transfer documentation    Other (describe below)

DECLARATION

By signing below, the Applicant certifies that the information contained in this Insurance Security Sale Supplement is true, complete, and submitted in good faith. The Applicant acknowledges that material misrepresentation or failure to disclose information relevant to the risk may result in denial of coverage, rescission of the policy, or adjustment of coverage and premium in accordance with policy terms. The Applicant authorizes the Insurer to rely on this Supplement in determining underwriting and coverage decisions and to request additional documentation as necessary.

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