I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT. I UNDERSTAND THAT ANY FALSE STATEMENTS OR UNLAWFUL ACTS WILL RENDER MY COVERAGE NULL AND VOID.
Signing this application does not bind the Company to provide insurance but it is agreed that this form shall be the basis of the contract should this policy be issued. If accepted for insurance, I authorize PIE to release personally identifiable financial information as applicable to affiliates and non-affiliates disclosed on the PIE Privacy Policy statement for purposes of reinsurance premium calculation, etc.
PIE APPLICATION, Page 3
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT. I UNDERSTAND THAT ANY FALSE STATEMENTS OR UNLAWFUL ACTS WILL RENDER MY COVERAGE NULL AND VOID
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT. I UNDERSTAND THAT ANY FALSE STATEMENTS OR UNLAWFUL ACTS WILL RENDER MY COVERAGE NULL AND VOID.
SUBSCRIBER’S AGREEMENT
WHEREAS, the undersigned is a resident of the State of Utah and is licensed to practice dentistry in the State of Utah;
WHEREAS, the undersigned desires to enter into membership among other subscribers of a mutual insurance company providing indemnity against professional liability, said mutual insurance Company shall be known as Professional Insurance Exchange Mutual, Inc. (PIE)
NOW THEREFORE, the undersigned agrees with PIE and the other subscribers
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To join with the other subscribers insuring against losses and to be subject to such terms and conditions and limits of liability as set forth in the policy. The terms, conditions and limits of liability of the policy shall be specified by the Company in compliance with sound and accepted insurance practices and reasonable standards established by the Subscribers' liability set forth herein.
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To make all premium payments and applicable surcharge payments when due for policies of insurance issued in accordance with schedules of rates prepared from time to time by the Company in compliance with sound and accepted insurance practices and reasonable standards established by the Company’s Board of Directors and approved by the Commissioner of Insurance of the state of Utah
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To abide by such rules and regulations of the Company as stated in the Bylaws or adopted by the Company’s Board of Directors from time to time.
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To release all past and current information pertaining to underwriting and claims by the undersigned's prior insurers or their agents.
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To the appointment of Richard C. Engar, D.D.S. as Chief Executive Officer (CEO) to administer the day-to-day operations of the Company and oversee underwriting of potential new subscribers.
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To allow the Subscribers' Board of Directors to supervise and control the activities of the Company.
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To authorize PIE to release personally identifiable financial information as applicable to affiliates and non-affiliates disclosed on the PIE Privacy Policies statement for purposes of reinsurance premium calculation, etc.
IT IS FURTHER AGREED that the subscribers' Board of Directors shall consist of nine members elected at the annual meeting of subscribers by the subscribers exercising one vote each. Board members shall be elected for terms of three years each. Terms shall be staggered such that three positions are due for election each year. Not less than eight such Board members shall be subscribers or members of PIE. The Subscribers' Board of Directors shall supervise the finances of Professional Insurance Exchange Mutual, Inc. and supervise its operations to assure conformity with this Agreement and the Bylaws of the Company, procure examinations or audits of the accounts and records of Professional Insurance Exchange Mutual, Inc. and shall have such additional powers and functions as may be conferred from time to time by majority vote of the subscribers.