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ERM-14 (Rev. 2/20) © Copyright 2018 National Council on Compensation Insurance, Inc. All Rights Reserved. Page 1 of 2 REQUEST FOR OWNERSHIP INFORMATION—ERM-14 FORM The purpose of this

© Copyright 2018 National Council on Compensation Insurance, Inc. All Rights Reserved. 1  ERM-14 Form Instructions How to Submit The ERM-14 Form is available on the Frequently Accessed Forms

© Application is hereby made for coverage (s), as specified per the signed attached quotation, to become effective on _______________________ , at 12:01 A.M. Central Standard Time at the address

Occupational Accident Application Occupational Accident Application Account Information List (or attach) subsidiary(s) or combinable entities if coverage is requested: Mileage Revenue Hourly

Innovation Growth Partners Specialty, LLC 1 Concourse Parkway, Suite 700 | Atlanta, Georgia 30328 (800) 232-5830 | igpspecialty.com Payment Instructions Important Note: Please reference

PAGE 1 OF 7 Financial Services Protection Insurance Application Administered by THIS IS AN APPLICATION FOR INSURANCE WRITTEN ON A “CLAIMS MADE AND REPORTED” BASIS WHICH APPLIES ONLY TO CLAIMS

A Strategic Specialty Partner for the Ironpeak Agent Network As specialty risks grow more complex and standard markets continue to tighten, Ironpeak agents need specialty partners who deliver broad

A Strategic Specialty Partner for the Ironpeak Agent Network As specialty risks grow more complex and standard markets continue to tighten, Ironpeak agents need specialty partners who deliver broad

A Strategic Specialty Partner for the Ironpeak Agent Network As specialty risks grow more complex and standard markets continue to tighten, Ironpeak agents need specialty partners who deliver broad

A Strategic Specialty Partner for the Ironpeak Agent Network As specialty risks grow more complex and standard markets continue to tighten, Ironpeak agents need specialty partners who deliver broad

A Strategic Specialty Partner for the Ironpeak Agent Network As specialty risks grow more complex and standard markets continue to tighten, Ironpeak agents need specialty partners who deliver broad

Put our expertise in healthcare risks to work for you. HEALTHCARE MARKETS ■ ACE/Westchester ■ Admiral ■ AIG ■ Allied World (AWAC) ■ Ambridge/Brit ■ American Empire ■ Applied Financial ■

Media Liability | Wholesale Brokerage COVERAGE FEATURES ■ Occurrence and Claims Made Options ■ Optional Defense Outside of Limits ■ Copyright and Trademark Infringement ■ Libel ■ Slander ■

Management Liability (D&O/EPL/Fiduciary/Crime/K&R) ■ Public Companies ■ Private Companies ■ Non-Profit Organizations ■ General Partner Liability ■ Healthcare Organizations ■ Financial

Real Estate E&O COVERAGE FORM FEATURES ■ First Dollar Defense ■ Additional Defense Limits ■ Aggregate Deductible ■ Consent to settle wording (Soft Hammer Clause) ■ Defense of Fair Housing

©2025 Innovation Growth Partners Specialty, LLC | igpspecialty.com REV 08.22.25 Social Services Risks | Wholesale Brokerage SOCIAL SERVICES CLASSES ■ Adult / Respite & Special Needs Day Care

TECHNOLOGY CLIENTS WE SERVE ■ Application Service Providers ■ Branding and Marketing Services ■ Business Process Outsourcing Firms ■ Cloud and Data Center Providers ■ Cyber Security Services ■

Page 1 of 3 INSURED INFORMATION NAMED INSURED INSURED ADDRESS CITY STATE ZIP WELL DETAILS WELL NAME CLOSEST ADDRESS CITY STATE ZIP WELL DEPTH ft COVERAGE COVERAGE BASIS Total

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Innovation Growth Partners Specialty, LLC | igpspecialty.com REV 06.26.25 CONTACT US Traci Huskey (941) 444-1659 | traci.huskey@igpspecialty.com Brian Rudolph (941) 444-1643 | brian.rudolph@