CLOSE WINDOW      $6MM - $10MM Special Acceptance Questionnaire   This form to be submitted for RENEWAL REQUESTS ONLY. New quotes should be submitted during online quote process.   All $6 - $10 Million quotes require special acceptance. You must complete / print this page + Fax with current MVRs to 510-655-3076 You will be notified via email of acceptance status. Broker Name: Producer ID: Insured Name: Navigators Policy #: Expiration Date: Insured Occupation: Spouse Occupation: _____ Initial   None of the applicants applying for this insurance are any of the following: Professional Entertainers-Actors, Actresses, Directors, Producers, Writers, TV/Radio Personalities. Or Athletics-All Professional Athletes, Coaches, Managers & Owners, NCAA Division I Athletes or Coaches that regularly appear on television. Or Public Officials-Elected/appointed officials to any state or federal office, Elected officials to cities, counties, courts Populations over 50,000. Or Famous People-Top Executives of Fortune 500 companies, Persons appearing regularly in the media due to their wealth or profession. _____ Initial   None of the applicants applying for this insurance have had four (4) or more losses or total losses over $25,000 within the past three years.

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