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General Instructions of Lost Instrument BondsCompleted Application - Please forward the original (signed andwitnessed) application.Financials – A current Balance Sheet or Fiscal-End Yearaccounting must be submitted. If applicant is an individual, pleasesubmit a list of current assets and liabilities.Collateral – Full collateral is required in most cases. A Letter ofCredit from a reputable bank is preferred. A copy of our sampleLetter of Credit can be found on our website. This is the formatthe Bank will have to follow. Other forms of collateral may beconsidered, please call one of our underwriters for moreinformation.Premium Payment – An Invoice will be included in your bondpackage. Please remit payment within 30 days from the issuanceof the bond. If you wish to pay the bond premium via creditcard, please call The Bar Plan at 877-553-6376 or visitwww.thebarplan.com and click on the Pay Online link.Please feel free to mail, fax or e-mail all required information to:The Bond Department622 Emerson Rd., Suite 100St. Louis, Missouri 63141Fax 888 658-6761bonds@thebarplan.comFA003 – Application for Lost Instrument Bond – 08/2020

The Bar Plan Surety and Fidelity CompanyThe Bar Plan Mutual Insurance Company1717 Hidden Creek Court, St. Louis, Missouri 63131, (314) 965-3333, Fax (314) 965-7812 orToll Free 877-553-6376, Fax (888) 658-6761Lost Instrument Bond ApplicationPlease print legibly or typeName of applicant:(Mr./Mrs./Ms.)First NameMiddle InitialLast NameA/K/A or Alias Name:Address:City:State:Zip:Type of Bond Requested: Amount of Bond:Name & Address of Obligee:(To whom will the bond be given?)If Applicant is an IndividualSocial Security #: Birth Date:Marital Status: Single Married Divorced WidowedDo you own a home?: Rent?: Other:Are you currently employed?:Employer:Position/If retired, previous position:If self employed, explain nature of businessAddress of Employer:City: State: Zip:Length of employment/ownership:Have you ever been convicted or pled guilty to a felony?If yes, please explain:Have you filed for personal bankruptcy?: If yes, when?:Provide the name of all banks at which you hold accounts.:FA003 – Application for Lost Instrument Bond – 08/2020

Lost Instrument Information:Serial Number and Description of Instrument (No. of shares, common or preferred, Name ofCompany, etc.)Date of Issue of Lost Instrument:Are Securities Payable to Bearer? Yes ( ) No ( ) Are Securities Endorsed? Yes ( ) No ( )Exact Name(s) of Owner(s) on Lost Instrument, if Registered:Describe Manner of Loss:Has Notice of Loss Been Given? Yes ( ) No ( ). What date?To Whom was Notice of Loss Given?Address:If the applicant is a corporation, please attach a copy of the corporation’s financialstatements.If the applicant is an individual, collateral is required. The preferred form of collateral is aLetter of Credit. The amount of collateral required must be equal to the bond amount plus theadditional fee as stated below:Bond AmountUp to 50,000 50,001 - 250,000 250,001 - 500,000 500,001 and upAdditional Fee added to collateralAn additional 1,000An additional 5,000An additional 10,000An additional 5% of the bond penaltyFA003 – Application for Lost Instrument Bond – 08/2020

Attorney InformationAttorney for Principal: Bar #Law Firm Name:Address:City: State: Zip:Phone No. Fax No.E-Mail Address:How did you hear about our bond program? Please circle one choice below:Print AdDirect MailerConferences/SeminarInternet/BannerPrior Use** Delivery Method .Regular Mail , USPS Priority Mail 2-5 day average (at the cost ofthe client) or Overnight (at the cost of the client)Overnight Acct #Registered Agent Name:Registered Agent Address:City: State: Zip:** The Bar Plan does not guarantee delivery times of third party shippers,i.e. USPS, Fed-Ex or UPS.Agent/Broker InformationName of Insurance Agent/Broker: Nancy MeyersName of Insurance Agency: Lawyers Mutual Insurance Agency, LLCAgent/Broker/Agency Address: 10503 Timberwood Circle, Suite 213City: LouisvilleState: KYPhone number: 502-568-6100Zip: 40223Fax No.: 502-568-6103E-Mail Address: meyers@lmick.comSS# or FEIN for Payee Agent/Broker License #:Are you paying fees to a subproducer? Y/N . If Yes, complete supplemental application.Note to Agent, Broker and/or Agency: Please submit a current copy of your Agent, Brokerand Agency License with Application.Note: If the application is not completed in its entirety, it may cause delay inissuing the bond.FA003 – Application for Lost Instrument Bond – 08/2020

Anti-Fraud NoticeThe following disclaimer applies only to applicants in the states of Washington andFlorida.“Any person who knowingly and with intent to injure, defraud, or deceive any insurer files astatement of claim or an application containing any false, incomplete, or misleading informationis guilty of a felony of third degree.”Anti-Fraud WarningApplicable to Maine, Tennessee and Virginia Applicants only“It is a crime to knowingly provide false, incomplete or misleading information to an insurancecompany for the purpose of defrauding the company. Penalties include imprisonment, fines anddenial of insurance benefits”.Anti-Fraud WarningApplicable to New York Applicants only“Any person who knowingly and with intent to defraud any insurance company or other personfiles an application for insurance or statement of claim containing any materially falseinformation, or conceals for the purpose of misleading information concerning any fact materialthereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civilpenalty not to exceed five thousand dollars and the stated value of the claim for each suchviolation.”Anti-Fraud NoticeApplicable to Kentucky Applicants Only“Any person who knowingly and with intent to defraud any insurance company or other personfiles an application for insurance containing any materially false information, or conceals for thepurpose of misleading information concerning any fact material thereto, commits a fraudulentinsurance act, which is a crime.”Anti-Fraud NoticeApplicable to Ohio Applicants Only"Any person who, with intent to defraud or knowing that he is facilitating a fraud against aninsurer, submits an application or files a claim containing a false or deceptive statement is guiltyof insurance fraud."Anti-Fraud NoticeApplicable to New Mexico, West Virginia, Rhode Island and Louisiana Applicants Only"Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefitor knowingly presents false information in an application for insurance is guilty of a crime andmay be subject to fines and confinement in prison.”Anti-Fraud NoticeApplicable to DC Applicants Only“WARNING! It is a crime to provide false or misleading information to an insurer for the purposeof defrauding the insurer or any other person. Penalties include imprisonment and/or fines. Inaddition, an insurer may deny insurance benefits if false information materially related to a claimwas provided by the applicant.”FA003 – Application for Lost Instrument Bond – 08/2020

Anti-Fraud NoticeApplicable to Indiana Applicants Only"Any person who knowingly, and with intent to defraud an insurer, files a statement of claimcontaining false presents, incomplete or misleading information commits a felony.”Anti-Fraud NoticeApplicable to Hawaii Applicants Only“For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim forpayment of a loss or benefit is a crime punishable by fines or imprisonment or both.”Anti-Fraud NoticeApplicable to New Jersey Applicants Only“Any person who includes any false or misleading information on an application for an insurancepolicy is subject to criminal and civil penalties.”Anti-Fraud NoticeApplicable to Pennsylvania Applicants Only“Any person who knowingly and with intent to defraud any insurance company or other personfiles an application for insurance or statement of claim containing any materially false informationor conceals for the purpose of misleading, information concerning any fact material theretocommits a fraudulent insurance act, which is a crime and subjects such person to criminal andcivil penalties.”Anti-Fraud NoticeApplicable to Oklahoma Applicants Only“WARNING! Any person who knowingly, and with intent to injure, defraud or deceive any insurer,makes any claim for the proceeds of an insurance policy containing any false, incomplete ormisleading information is guilty of a felony.”Anti-Fraud NoticeApplicable to Colorado Applicants Only“It is unlawful to knowingly provide false, incomplete or misleading facts or information to aninsurance company for the purpose of defrauding or attempting to defraud the company. Penaltiesmay include imprisonment, fines, denial of insurance and civil damages. Any insurance companyor agent of an insurance company who knowingly provides false, incomplete or misleading factsor information to a policyholder or claimant for the purpose of defrauding or attempting to defraudthe policyholder or claimant with regard to a settlement or award payable from insurance proceedsshall be reported to the Colorado division of insurance within the department of regulatoryagencies.”Anti-Fraud NoticeApplicable to Maryland Applicants Only"Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss orbenefit or who knowingly or willfully presents false information in an application for insurance isguilty of a crime and may be subject to fines and confinement in prison.”Anti-Fraud NoticeApplicable to Alabama Applicants Only"Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit orwho knowingly presents false information in an application for insurance is guilty of a crime andmay be subject to restitution fines and confinement in prison, or any combination thereof.”FA003 – Application for Lost Instrument Bond – 08/2020