Thank you for your interest in the Professional Liability Insurance Plan for IEEE members.

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Bennett Stephens
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1 Mercer Cnsumer, a service f Mercer Health & Benefits Administratin LLC PO Bx 8146 Des Mines, IA Phne: Fax: Dear IEEE Member: Thank yu fr yur interest in the Prfessinal Liability Insurance Plan fr IEEE members. We have great news t share with yu! $2,000,000 limit f liability is nw available, and the licensing requirement as nted in questin 1.c. has been eased. Yur license number wuld nly be required if yur state requires that yu have a PE license fr the wrk yu perfrm. In additin, please nte n yur applicatin if yu hld the CSDA r CSDP designatin r have attended the IEEE Risk Management Seminar. A premium credit may apply. IEEE members enjy the fllwing benefits f cverage: Nearly all plicies are free f deductible r retentin Ideal prtectin fr firms r self-emplyed individuals Licensing bard defense cverage Expert legal cunsel t represent yu Negtiated members-nly rates Technlgy related prfessinal services endrsements Premium financing t help balance budgets If yu prvide cmputer-related services frm yur hme-based business, yu may qualify fr the general liability insurance ptin. It is recmmended that yu carry prfessinal and general liability insurance fr cmplete prtectin f yur business. Shuld yu have any questins, please call ur ffice tll-free at Sincerely, Timthy R Weber, Partner Mercer Health & Benefits Administratin LLC License # Mercer Cnsumer, a service f Mercer Health & Benefits Administratin LLC In CA d/b/a Mercer Health & Benefits Insurance Services LLC AR Ins. Lic. # CA Ins. Lic. #OG39709

2 P.C A IEEE-SPONSORED Prfessinal Liability Insurance Applicatin (This is an applicatin fr a Claims-Made Plicy.) NOTE: PLEASE REVIEW A SPECIMEN EVIDENCE OF INSURANCE FOR COVERAGE PROVISIONS. The limits f liability stated in the plicy are reduced by csts, charges and expenses. Csts, charges and expenses als may be applied against yur deductible, if applicable t the claim. Name Address City Daytime Phne N. State ZIP ( ) Fax N. ( ) Address We will use fr crrespnding unless therwise requested. 1. Legal Entity (please check ne): Individual A. Entity name (if applicable) B. Year established C. List each engineer in yur firm belw. Name Prfessinal Crpratin IEEE Membership I.D. Number (at least ne required fr acceptance) Crpratin Year first licensed as an engineer (if applicable) Partnership LLP/LLC Membership Grade Member Senir Member Fellw D. Indicate the size f yur staff (list each individual nly nce): Principals, Partners, Officers and Directrs Engineers (ther than principals) Other Technical Staff (describe psitin) Clerical TOTAL 2. A. Please select the limits f liability fr which yu wuld like a qutatin: $100,000 each claim/$300,000 annual aggregate $250,000 each claim/$500,000 annual aggregate $500,000 each claim/$500,000 annual aggregate $1,000,000 each claim/$1,000,000 annual aggregate $1,500,000 each claim/$1,500,000 annual aggregate $1,000,000 each claim/$2,000,000 annual aggregate $2,000,000 each claim/$2,000,000 annual aggregate B. Check if yu wuld like t purchase an additinal limit equal t the limit selected (nt t exceed $1,000,000) in 2A t apply t defense csts nly. 3. A. Please prvide yur actual grss billings fr the past 12 mnths. $ B. Please prvide an estimate f yur grss billings fr the next 12 mnths. $ Annual Grss Billings is defined as all amunts billed fr engineering services including incidental charges and subcntractr billings excluding direct reimbursable expenses. www (ver, please)

3 4. In the past five years, have yur annual grss billings ever exceeded the amunt in questin number 3A by 50 r mre?... Yes N If Yes, please prvide, n a separate sheet, yur annual grss billings fr each f the past five years and an explanatin f what caused the fluctuatin in yur grss billings. 5. I am aware that the plicy fr which I am applying prvides n cverage fr wrk perfrmed n behalf f any emplyer ther than the entity in questin 1a.... Yes N 6. Requested effective date 7. Please describe in detail the nature f yur practice (including types f prjects) 8. In which f the fllwing areas d yu r yur firm practice? Please indicate the apprximate percentages f yur annual r anticipated ttal grss billings derived frm each prject type. f Annual Grss Billings Area Aerspace/Aircraft Acustics Speech & Signal Prcessing Antennas Bradcast Technlgy Circuitry Cmmunicatins Cmputer Hardware* Cmputer Sftware* Cnsumer Electrnics Cntrl Systems Electrmagnetic Cmpatibility Expert Witness/Frensic Gescience Other (please specify) f Annual Grss Billings Area Industrial Electrnics Laser & Electr-ptics Magnetics Manufacturing Technlgy Medicine/Bilgy Micrwave Nuclear & Plasma Sciences Oceanic Pwer Electrnics Pwer Engineering Rbtics Ultrasnics, Ferrelectrics Vehicular Technlgy TOTAL 100 *Please cmplete the attached Cmputer Services Supplement frm. 9. A. Please prvide the fllwing infrmatin regarding the three largest prjects yu participated in during the past five years and indicate if such services were perfrmed fr an emplyer (E) r as a self-emplyed engineer (SE). Prject Type Services Perfrmed Date Services Perfrmed Yur Ttal Grss Billings Estimated Ttal Cnstructin Csts E r SE B. Are the prjects listed abve cnsistent with the type f prjects anticipated fr the future?... If N, please explain n a separate sheet f paper. Yes N (next page, please)

4 10. Please check Yes, N r N/A fr all risk management practices that yu adhere t in yur self-emplyed engineering practice Yes N N/A r wuld adhere t shuld the situatin apply. Please explain any n respnses n a separate sheet. A. B. C. D. E. F. G. H. D yu cnsistently exceed the minimum number f cntinuing educatin hurs required in yur state?... D yu use written scpe f service letters fr all prjects exceeding $500 in billable fees?... D yu cnduct cnstructin phase inspectin n plans and designs t ensure intent f use?... D yu make use f limitatin f liability clauses in engagement letters?... D yu use written status mems ver the curse f the prject?... D yu investigate the wrk experience f ther prfessinals t identify a ptential fr prblems?... D yu require that ther prfessinals n the prject carry cmparable prfessinal liability insurance?... D yu maintain written quality cntrl prcedures, including secndary design review?... Please explain n a separate sheet. Are all apprpriate staff members familiar with them? A. Has the applicant, r an independent cntractr hired by the applicant, accepted jbs invlving knwn Yes hazardus materials?*... B. D yu cntemplate accepting knwn hazardus material jbs in the future?... If yu answered Yes t either questin, please prvide a narrative descriptin including the date (year) f service, nature f hazardus material, type f prject, fees earned and nature f services prvided. Include a sample cpy f an engagement/scpe f service letter r cntract used fr these types f jbs. N * Engineering services that culd invlve hazardus materials r pllutants include but are nt limited t: Undergrund strage tank remval, assessment r remediatin; sanitary landfill design; clsure f existing sanitary landfills; asbests sampling, testing r abatement; chemical piping and prcess design; preparatin f envirnmental site assessments r audits, including Phase I and Phase II assessments/investigatins; grundwater testing/remediatin; labratry testing/analysis fr pllutants; air emissin cntrl systems designed slely fr cntrlling pllutants; site selectin evaluatin fr pllutin-related prjects; hazardus r txic waste site design r remediatin; lead paint sampling, testing r abatement; site selectin evaluatin fr pllutin-related prjects; air quality assessments/testing; envirnmental educatin; water pllutin cntrl; r nuclear-related prjects. 12. Please answer the fllwing questins. If the answer t any questin is Yes, please prvide the questin number and full details, including percentage f revenues derived frm the activity, n a separate sheet f paper. A. Are yu invlved in actual cnstructin, fabricatin, erectin, installatin f equipment, design/build Yes r supplying f cnstructin materials?... B. Have yu develped, sld r leased cmputer sftware/hardware t thers?*... C. D yu subcntract wrk t thers?... If Yes, d yu require all subcntractrs t carry insurance t cver the services they perfrm?... D. D yu manufacture, sell, lease r distribute any prduct, machinery r prcess?... E. Are yu wned by, r d yu wn, any ther firm?... If s, d yu render prfessinal services t the firm(s)?... F. Have yu filed any suits fr cllectin f yur prfessinal fees against a client during the past fiscal year? If Yes, please prvide full details n a separate sheet f paper. G. Des any single client accunt fr 25 r mre f yur annual grss incme?... If Yes, please prvide full details n a separate sheet f paper. N *Please cmplete the attached Cmputer Services Supplement frm. 13. A. List Engineers Prfessinal Liability Insurance carried by yu r yur firm fr the past tw years. Inceptin Date M.-Day-Yr. Expiratin Date M.-Day-Yr. Insurance Cmpany Annual Premium Limit f Liability If nne, state nne. Deductible B. Please prvide yur plicy s current retractive date If nne, state nne. C. Please prvide the date that yu/yur firm first purchased claims-made prfessinal liability cverage and have since cntinuusly maintained the cverage / /. If nt applicable, please check N/A (mm) (dd) (yy) D. If currently insured, please submit a cpy f yur current declaratins page with yur cmpleted applicatin. (ver, please)

5 14. A. Has any applicatin r plicy f yurs r yur firm s fr Prfessinal Liability Insurance ever been declined, canceled r refused renewal? If Yes, please prvide details n a separate sheet f paper... B. Have yu r members f yur firm had yur license revked r received suspensin r ther disciplinary actin frm a gvernmental r judicial bdy r prfessinal sciety during the past five years?... If Yes, please prvide details, including a cpy f the ruling. C. Have any claims been made r legal actins been brught against yu r yur firm in the past five years?* D. Are yu r any member f yur firm, aware f any circumstances that may result in a claim being made against the firm r any individual?*... Yes N *If Yes, please cmplete the Claim Infrmatin Supplement frm enclsed fr each claim and/r circumstance. 15. Please prvide yur website address, a cpy f yur current résumé, letterhead and typical advertising/sales/marketing brchures used by yu r yur firm. NOTICE TO APPLICANT: I/We hereby declare that the abve statements and particulars are true t the best f my/ur knwledge and that I/We have nt suppressed r misstated any material facts and I/We agree that this applicatin shall be the basis f the issuance f insurance cverage, and shall be attached theret. I/We hereby authrize the release f claim infrmatin frm any prir insurer t the Underwriters. I understand and accept that the plicy applied fr prvides cverage n a claims-made basis fr ONLY THOSE CLAIMS THAT ARE FIRST MADE AND REPORTED TO THE COMPANY DURING THE POLICY PERIOD FOR ACTS THAT OCCUR AFTER THE POLICY S RETROACTIVE DATE AND PRIOR TO THE EXPIRATION DATE OF THE POLICY. Signature f Owner, Officer r Partner (TITLE) X Date X Signing this frm and tendering premium des nt bind the applicant r the Underwriters t cmplete the insurance. Applicatin must be currently signed and dated t be cnsidered fr qutatin. Sign, date and mail yur applicatin t: IEEE Insurance Plans, P.O. Bx 8146, Des Mines, IA ; r fax yur applicatin t QUESTIONS? CALL TOLL FREE AIF 2384 A (8/13) A16022 (8/13) NOTICE: Failure t reprt any: 1) claim made against yu during yur current plicy term, r Underwritten by: Certain Underwriters at Llyd s f Lndn Administered by: Cpyright 2014 Mercer LLC. All rights reserved. Mercer Cnsumer, a service f Mercer Health & Benefits Administratin LLC 2) facts, circumstances r events that may give rise t a claim t yur current insurance cmpany BEFORE plicy expiratin may create a lack f cverage.

6 CLAIM INFORMATION SUPPLEMENT Cmplete this supplement if any claims have been made r legal actins have been brught against yu r yur firm in the past five years (if renewal, within the last year), r if yu r any member f yur firm are aware f any circumstance that may result in a claim being made against the firm r any individual. COMPLETE ONE FORM FOR EACH CLAIM OR INCIDENT. 1. Full name f party making claim (claimant): 2. Rle f claimant (e.g., wner, cntractr, etc.): 3. Indicate whether: claim lawsuit incident nly 4. Date f alleged errr: 5. Date claim reprted t yu: 6. Descriptin f claim/incident: A. Alleged act, errr r missin upn which claimant bases claim: B. Descriptin f events leading t claim: 7. Amunt f damages claimed: 8. Additinal defendants: 9. Name f insurer fr this claim/incident: 10. If Clsed: Ttal deductible paid: $ Indicate ttal lss paid in excess f the deductible: $ Indicate ttal defense expenses paid in excess f the deductible: $ If Pending: Claimant s settlement demand: $ If suit filed, amunt asked in cmplaint: $ Insurer s lss reserve: $ Defense expenses t date: $ 11. Explain what actin has been taken t prevent a recurrence f a similar claim: The undersigned represents that the statements set frth herein are true, cmplete and accurate, and that there has been n attempt at suppressin r misstatement f any material facts knwn, and agrees that this applicatin shall becme the basis f any cverage and a part f any plicy that may be issued by the Cmpany. X Signature (Owner, Officer r Partner) Applicant/Firm Name (Please Print) Date AIF2384 CI (4/99)

COMPUTER SERVICES SUPPLEMENT If yur area f practice includes cmputer hardware r sftware services, r if yu have ever develped, sld r leased cmputer sftware/hardware t thers, please cmplete this

7 COMPUTER SERVICES SUPPLEMENT If yur area f practice includes cmputer hardware r sftware services, r if yu have ever develped, sld r leased cmputer sftware/hardware t thers, please cmplete this supplement with respect t cmputer-related services. 1. Please describe in detail the nature f prfessinal services yu prvide invlving cmputer hardware r sftware and describe yur clientele: 2. Indicate the percent f grss incme derived frm the fllwing: Electrnic data prcessing Systems analysis Sftware design Prgramming Cmputer/systems cnsulting Cmputer/systems installatin/supprt Other cmputer-related services (define) Ttal = If yu are invlved in sftware design, please state whether the sftware will be used by mre than ne client and describe the end use f the sftware: 4. Have yu been invlved in any prject invlving the integratin f embedded chips r any type Yes N f cmputer hardware r sftware? If Yes, please describe in detail the end use f the hardware r sftware: 5. Please prvide the fllwing infrmatin regarding yu/yur firm s qualificatins t prvide prfessinal services: Name f Individual Perfrming Prfessinal Services Prfessinal Qualificatins (such as CSDA r CSDP designatin) Educatinal Degree and Years f Experience Hw Lng in Practice AIF 2384 CS-2 (08/13) Page 1 f 2

8 6. Please prvide the fllwing infrmatin regarding the three largest cmputer-related jbs r prjects by revenue that yu participated in during the past five years: Prject/Client Name Cmputer Prject Applicatin Type f Prfessinal Services Prvided Revenue Obtained Frm Thse Services 7. Please answer the fllwing questins. If the answer t any questin is Yes, please prvide the questin number and the full details n a separate sheet f paper. A. D yu maintain r require training r cntinuing educatin prgrams fr emplyees? Yes N B. D yu currently carry Cmprehensive General Liability cverage r Umbrella cverage? 8. List wh is respnsible fr quality cntrl, and briefly describe yur quality cntrl prgrams in place: 9. Please prvide a descriptin f yur testing and sign-ff prcedures: 10. If yu are applying as an Individual, wuld yu like a qute fr General Liability cverage Yes N (in additin t Prfessinal Liability)?... If YES, please answer the fllwing questins: A. D yu perate yur business at a lcatin ther than yur hme?... B. If yu subcntract services, what percentage f yur grss billings emanates frm wrk subcntracted t thers?.. C. D yu require subcntractrs t carry General Liability cverage with limits that match r exceed yur wn?... D. D yu require that subcntractrs name yu/yur business as an Additinal Insured n their General Liability plicy? The undersigned represents that the statements set frth herein are true, cmplete and accurate, and that there has been n attempt at suppressin r misstatement f any material facts knwn, and agrees that this applicatin shall becme the basis f any cverage and a part f any plicy that may be issued by the cmpany. X Signature (Owner, Officer r Partner) Applicant/Firm Name (please print) Date AIF 2384 CS-2 (08/13) Page 2 f 2

Dear ASME Member: Thank you for your interest in ASME-endorsed Professional Liability Insurance Plan.

Mercer Consumer, a service of Mercer Health & Benefits Administration LLC PO Box 8146 Des Moines, IA 50306-8146 Phone: 800-640-7637 Fax: 515-365-3043 Dear ASME Member: Thank you for your interest in ASME-endorsed