Exhibit_AC-Ambridge_Partners_LLC_-_SIR_Package_Application-Outsourcing.pdf

OUTSOURCING OF SERVICES AND FUNCTIONS

No

If yes, please describe the service(s) outsourced?

FOR EACH AND EVERY OUTSOURCED SERVICE, PLEASE ANSWER THE FOLLOWING QUESTIONS?

1. What is the full legal name of the third party that will actually be providing the service or function?

2. What are the specific agreements in place with the contracted third party in regard to insurance and indemnity?

3. Do you have a written contract or agreement with the contracted third party and a certificate of insurance or other proof of coverage in regard to the service or function? (You may be asked to provide copy of the contract or certificate of insurance)

Does the applicant outsource any services or functions, either internal or external, to a third-party, i.e. transportation, waste collection, administration of employee benefits, etc.?

PSI v20091201

CHECKLIST

Have you supplied the following information with this application?

Full and latest COPE property schedule of values in Excel

Automobile schedule of values in Excel

Copies of the most recent financial statement and annual report

Policies & Procedures manual for employment practices and Sexual Harassment

Policies & Procedures Manual for Sexual Abuse/Misconduct

Workers Compensation Payroll by Class Code

ADDITIONAL APPLICATIONS

Have you completed the additional applications for obtaining a quote for supplemental coverages?

1. Law Enforcement Liability

2. Sexual Abuse Liability

3. Social Services Application

4. Higher Education Institutions

5. Dam/Levees/Reservoirs

6. Utilities

7. Transit Authority

Ground-up and uncapped loss data for the last 5 full years plus current year minimum valued at no earlier than 90 days prior to inception

DECLARATION

Agree / Disagree Name of Assured / Legal Representative / Agent Date

Please confirm that you have read and agree with the above statement -

NOTICE:

THE UNDERSIGNED(S) CERTIFIES THAT HE/SHE IS THE DULY AUTHORIZED

REPRESENTATIVE(S) OF EACH PROPOSED ASSURED WHO SUBMITS THIS APPLICATION TO

AMBRIDGE PARTNERS LLC FOR A POLICY OF INSURANCE.

THE UNDERSIGNED REPRESENTS THAT THE STATEMENTS SET FORTH IN THE APPLICATION

ARE TRUE AND CORRECT TO THE BEST OF THEIR KNOWLEDGE, AND THAT REASONABLE

EFFORTS HAVE BEEN MADE TO OBTAIN INFORMATION WHICH IS SUFFICIENT AND ACCURATE

FOR THE PURPOSES OF OBTAINING THIS PROPOSED INSURANCE.

THE APPLICATION WARRANTS THAT IF THE INFORMATION SUPPLIED ON THE APPLICATION

CHANGES BETWEEN THE DATE OF THIS APPLICATION AND THE INCEPTION DATE OF THE

POLICY PERIOD, YOU SHALL IMMEDIATELY NOTIFY AMBRIDGE PARTNERS LLC OF SUCH

CHANGE.

SIGNING OF THIS APPLICATION DOES NOT BIND AMBRIDGE PARTNERS LLC TO OFFER OR THE

APPLICANT TO ACCEPT INSURANCE, BUT IT IS AGREED THAT THIS APPLICATION SHALL BE

THE BASIS OF THE INSURANCE CONTRACT AND WILL BE ATTACHED AND MADE PART OF THE

POLICY SHOULD A POLICY BE ISSUED.