NAME: _________________________________

Date: ______________________________

Account #: __________________________

To Whom it May Concern:

I wish to increase my Limits of Liability on my Psychologist Professional Liability policy #_______________________ from $_____________________ to $_____________________.

For your underwriting purposes:

"I HEREBY WARRANT THAT I AM NOT AWARE OF ANY ACT, ERROR OR OMISSION, WHICH MIGHT REASONABLY BE EXPECTED TO GIVE RISE TO A CLAIM UNDER THIS POLICY.

"I UNDERSTAND THAT THIS LETTER WILL BE ATTACHED TO AND BECOME PART
OF THE SAID POLICY."

_________________________________________
Signature of Named Insured

_________________________________________
Date