Professional Liability Insurance - Mandatory Disclosure Form per SCR 79

State Bar of Nevada Please use this form to report new or additional professional liability insurance. Bar Number Last Name First Name MI SCR 79 PROFESSIONAL LIABILITY INSURANCE DISCLOSURE All members, active or inactive, MUST complete this section. Please select ONE option. I am not currently representing clients; or I am engaged as a full or part-time government lawyer or judge; or I am employed by an organizational client and do not represent clients outside that capacity. If you check this box, you are done, please sign and date at the bottom of this page. I am engaged in the private practice of law and do not maintain professional liability insurance. If you check this box, you are done, please sign and date at the bottom of this page. I am engaged in the private practice of law and, I or my firm, maintain professional liability insurance with the carrier listed below. This includes insurance from ANY state. If you check this box, you MUST disclose the following: Firm Name (if you are reporting insurance): Names of Insurance Carrier (not broker): Address: City: State: Zip: I certify all of the above disclosures required by SCR 79 are true and complete. Signature Date Please return to: State Bar of Nevada P.O. Box 50 Las Vegas, NV 89125-0050 American LegalNet, Inc. www.FormsWorkFlow.com