Legal Liability Questionnaire

LEGAL LIABILITY QUESTIONNAIRE

This Legal Liability Questionnaire ("Questionnaire") is dated as of and is submitted by Client Name: with Address: to Recipient Name: with Address: .

RECITALS

WHEREAS, Client Name represents that it seeks to disclose information regarding potential liabilities, claims, exposures, insurance coverages and risk management practices to Recipient Name for the purposes of underwriting, evaluation, or legal review; and

WHEREAS, Recipient Name requires factual and sworn representations regarding past, pending and potential claims and exposures in order to evaluate legal liability and to make informed determinations concerning contractual allocation of risk, indemnities, or insurance placement; and

WHEREAS, the parties desire that the statements and attachments provided hereafter be accurate, complete and certified by authorized representatives of the parties under penalty of liability for material misrepresentation.

NOW, THEREFORE, in consideration of the mutual covenants and for other good and valuable consideration, the parties agree as follows:

1. INSTRUCTIONS

Complete each item fully and attach supplemental documentation where requested. Responses must be truthful and based on the best knowledge of the person completing this Questionnaire. If an item is not applicable, indicate "N/A." If additional space is required, attach labeled exhibits and reference the exhibit here.

2. ORGANIZATIONAL INFORMATION

Corporation LLC Partnership Individual/Sole Proprietor

3. INSURANCE COVERAGE

Provide current primary liability insurance coverages. Carrier: Policy Number: Limits (each occurrence/aggregate): Expiration Date:

Are there any exclusions, notices of cancellation, or disputed coverage pending? Yes No

4. CLAIMS AND LITIGATION HISTORY

Has the entity or any officer, director, owner or principal been named in any litigation, arbitration, administrative proceeding, or claim in the past ten (10) years? Yes No

5. CONTRACTS, INDEMNITIES AND THIRD-PARTY OBLIGATIONS

Does the entity enter into contracts that (a) require the entity to indemnify another party for third-party claims, (b) include hold harmless clauses, or (c) transfer liability to subcontractors? Yes No

6. REGULATORY, COMPLIANCE AND LICENSING

Is the entity subject to industry-specific regulation or licensing that could give rise to administrative enforcement, fines or revocation? Yes No

7. INTELLECTUAL PROPERTY AND THIRD-PARTY CLAIMS

Has the entity received any claims alleging infringement, misappropriation, or violation of third-party intellectual property rights? Yes No

8. POTENTIAL EXPOSURES AND RISK MITIGATION

9. REPRESENTATIONS AND WARRANTIES

The undersigned certifies, on behalf of the party identified below, that the responses in this Questionnaire are true, complete and accurate as of the date signed, that no material facts have been omitted, and that any material change in circumstances will be promptly disclosed in writing to Recipient Name. The undersigned further acknowledges that Recipient Name may rely upon these statements in assessing liability, indemnity and insurance matters.

10. CONFIDENTIALITY

All information provided in this Questionnaire and associated exhibits shall be treated as confidential by Recipient Name, except insofar as disclosure is required by law, regulation, subpoena, or where necessary for defense of a claim. Recipient Name shall use the information solely for the purposes described in the Recitals.

11. MISCELLANEOUS PROVISIONS

Governing Law.

This Questionnaire shall be governed by and construed in accordance with the laws of the jurisdiction where Recipient Name maintains its principal place of business, without regard to conflict of law principles. The parties submit to exclusive jurisdiction for disputes arising out of this Questionnaire.

Entire Agreement.

This Questionnaire, together with any attachments and exhibits, constitutes the entire agreement between the parties relating to the subject matter hereof and supersedes all prior oral or written communications and understandings.

Severability.

If any provision of this Questionnaire is held to be invalid or unenforceable by a court of competent jurisdiction, the remaining provisions shall remain in full force and effect and such invalid or unenforceable provision shall be reformed only to the extent necessary to make it enforceable.

Notices.

Amendments and Waiver: No amendment, modification or waiver of any provision of this Questionnaire shall be effective unless in writing and signed by authorized representatives of both parties. The failure of either party to enforce any provision shall not constitute a waiver of future enforcement of that or any other provision.

12. ATTESTATION

The undersigned, being duly authorized, certifies under penalty of perjury that the foregoing information is true, complete and accurate to the best of their knowledge and belief as of the date signed below. The undersigned acknowledges that false statements or omissions may subject the signer and the entity to liability, including rescission of coverage or denial of indemnity where reliance upon this Questionnaire was material.

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