Insurance Patent

							                         m            American International Companies®

Name of Insurance Company
To Which Application Is Made:




                           PATENT INFRINGEMENT INSURANCE APPLICATION


NOTICE: THIS IS AN APPLICATION FOR A CLAIMS MADE FORM. THE COVERAGE OF THE POLICY IS
LIMITED GENERALLY TO INDEMNITY FOR ONLY THOSE CLAIMS THAT ARE FIRST MADE AGAINST THE
INSURED AND REPORTED IN WRITING TO THE COMPANY WHILE THE POLICY IS IN FORCE.

NOTICE: THE LIMIT OF INDEMNITY AVAILABLE TO PAY JUDGMENTS OR SETTLEMENTS SHALL BE
REDUCED BY AMOUNTS INCURRED FOR LEGAL DEFENSE. AMOUNTS INCURRED FOR LEGAL DEFENSE
SHALL BE APPLIED AGAINST THE RETENTION AMOUNT.

IF CONFIDENTIALITY AGREEMENT IS DESIRED BY THE APPLICANT, PLEASE HAVE YOUR INSURANCE
BROKER NOTIFY THE INSURANCE COMPANY.


1.     a.      Name of applicant:

       b.      Mailing address:



2.     Applicant/predecessors have been continuously operating since:



3.     a.      Limits of indemnity requested:                                        /
                                                                        (each Claim / aggregate)

               Sub limits for Injunction Expenses:                                  /
                                                                        (each Claim / aggregate)

       b.      Retention requested:                                                 each Claim

                                                                                    each Injunction Claim

       c.      Coinsurance requested:                                     percent



4.                                                                                   s
      Please list all shareholders holding ten percent (10%) or more of the applicant’ issued voting shares in all
      classes, together with the percent held by each such shareholder.




60947 (3/96)                                           -1-
5.    Has the applicant been involved in any past, ongoing, planned or completed merger or acquisition within the past
      five (5) years?
       ]
      [ Yes            ]
                      [ No         If yes, provide details.




6.    What are the customary royalty rates for patent licenses in the industry(ies) in which the applicant manufactures,
      sells, uses, distributes or advertises? Provide the following information for each such industry:

       [ 0-5%
        ]               [ 6-10%
                         ]              [ 11-15%
                                         ]                ]
                                                         [ 16-20%       [ OVER 20%
                                                                         ]



7.    a.       Does the applicant have a procedure, written or otherwise, to safeguard against infringing patent rights of
               others?
                ]
               [ Yes        ]
                            [ No

               If yes, please attach a copy or written description of that procedure.



       b.      Does that procedure include a search for existing patents and potential infringements?
                ]
               [ Yes         ]
                            [ No



      c.       Do in-house or outside patent attorneys or patent agents conduct that procedure?
               [ Yes
                ]            ]
                             [ No

               Is a written opinion from a patent attorney required?
                ]
               [ Yes         ]
                            [ No

               Attach an outline of the education, qualifications and experience of the three senior-most individuals
               involved in that procedure.


       d.      In the event that the applicant becomes aware of a potential infringement, what procedure would the
               applicant follow to terminate or avoid such infringement? In such event, would the applicant perform a
               patent search, negotiate a license, purchase patent rights, redesign to avoid infringement, commence an
               action to have the potentially infringed patent declared invalid or seek to have the potentially infringed
               patent re-examined?




8.     a.       DURING THE PAST FIVE (5) YEARS, WITH RESPECT TO ANY POSSIBLE OR ACTUAL CLAIM OF PATENT
               INFRINGEMENT AGAINST THE APPLICANT, HAS THE APPLICANT:

               (1)   received any notice or warning, whether written or oral?                            ]
                                                                                                        [ Yes      ]
                                                                                                                  [ No

               (2)   been involved in any legal action or proceeding, whether past or pending?           ]
                                                                                                        [ Yes      ]
                                                                                                                  [ No



60947 (3/96)
                                                              -2-
               (3)   made any inquiry or sought any advice                                               ]
                                                                                                         [ Yes          ]
                                                                                                                       [ No


               If the applicant answers “yes” to any of the foregoing, items 8.a. (1)-(3), provide the following details:

               (1)   the type, date and circumstances of the claim, including all written notices;


               (2)   a copy of all material information relating to any agreements(s) of settlement of such claim(s); and

               (3)   policies and practices adopted to prevent a recurrence of such claim(s).


      b.       Is any patent infringement litigation threatened or pending, whether or not the applicant is a party thereto,
               that could have an impact on the applicant?
                [ Yes
                ]            ]
                             [ No         If yes, provide details.



      c.       Is there any circumstance of which the applicant is aware (e.g., any application for a patent pending by
               anyone other than the applicant) that could be reasonably expected to give rise to a claim against the
               applicant alleging patent infringement either based on past, current or future planned or continued
               manufacture, sale, use, distribution or advertising by the applicant?
                [ Yes
                 ]            ]
                             [ No         If yes, provide details.



9.    IT IS AGREED WITH RESPECT TO QUESTION NUMBER 8 ABOVE, THAT IF SUCH KNOWLEDGE,
      INFORMATION, CIRCUMSTANCES OR INVOLVEMENT EXISTS, ANY CLAIM, ACTION OR PROCEEDING
      ASSOCIATED THEREWITH OR ARISING THEREFROM IS EXCLUDED FROM THE COVERAGE FOR WHICH
      APPLICATION IS MADE.



10. What “hold harmless” and/or liability, indemnification, waiver or subrogation agreements has the applicant
    entered into with third parties (suppliers, distributors, customers, etc.) as respects intellectual property rights?




11. Please provide the following:

      a.       A current annual report and audited financial statements, and form 10K if publicly traded.

      b.       A complete list and description of all products manufactured, distributed, used, sold or advertised by the
               applicant. Please also enclosed catalogs, brochures and other advertising or sales material.

      c.       The total number of valid and enforceable patents owned or as to which rights are licensed by the
               applicant.

      d.       The total number of patent applications filed in each of the past two calendar years and through the date of
               this application in this calendar year.



                                                              -3-
60947 (3/96)
ALL WRITTEN STATEMENTS AND MATERIALS FURNISHED TO THE COMPANY TO WHICH THIS APPLICATION IS
SUBMITTED (HEREIN CALLED THE COMPANY) IN CONJUNCTION WITH THIS APPLICATION ARE HEREBY
INCORPORATED BY REFERENCE INTO THIS APPLICATION AND MADE A PART HEREOF.

THIS APPLICATION DOES NOT BIND THE APPLICANT TO BUY, OR THE COMPANY TO ISSUE THE INSURANCE,
BUT IT IS AGREED THAT THIS FORM SHALL BE THE BASIS OF THE CONTRACT SHOULD A POLICY BE ISSUED,
AND IT WILL BE ATTACHED TO AND MADE A PART OF THE POLICY. THE UNDERSIGNED APPLICANT DECLARES
THAT THE STATEMENTS SET FORTH IN THIS APPLICATION ARE TRUE. THE APPLICANT FURTHER DECLARES
THAT IF THE INFORMATION SUPPLIED ON THIS APPLICATION CHANGES BETWEEN THE DATE OF THIS
APPLICATION AND THE TIME WHEN THE POLICY IS ISSUED, THE APPLICANT WILL IMMEDIATELY NOTIFY THE
COMPANY OF SUCH CHANGES, AND THE COMPANY MAY WITHDRAW OR MODIFY ANY OUTSTANDING
QUOTATIONS AND/OR AUTHORIZATION OR AGREEMENT TO BIND THE INSURANCE.

NOTICE: IN SOME STATES, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY
INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF
CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF
MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT
INSURANCE ACT, WHICH IS A CRIME. IN NEW YORK, A PERSON WHO COMMITS SUCH CRIME SHALL ALSO
BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED $5000 AND THE STATED VALUE OF THE CLAIM FOR
EACH SUCH VIOLATION.




SIGNATURE:                                                                                  s
                                                    Must be signed by the applicant’ president,
                                                    general counsel or director of risk management (or
                                                    other officer responsible for such function)
TITLE:




DATE:



IF A POLICY IS ISSUED THE APPLICATION IS ATTACHED TO AND MADE A PART OF THE POLICY SO IT IS
NECESSARY THAT ALL QUESTIONS BE ANSWERED IN DETAIL.

PLEASE READ THE FOLLOWING CAREFULLY AND SIGN BELOW WHERE INDICATED. IF A POLICY IS ISSUED,
THIS SIGNED STATEMENT WILL BE ATTACHED TO THE POLICY.

THE INSURED HEREBY ACKNOWLEDGES THAT THE INSURED IS AWARE THAT THE LIMIT OF INDEMNITY
CONTAINED IN THIS POLICY SHALL BE REDUCED, AND MAY BE COMPLETELY EXHAUSTED, BY THE COSTS
OF LEGAL DEFENSE AND, IN SUCH EVENT, THE COMPANY SHALL NOT BE LIABLE FOR THE COSTS OF LEGAL
DEFENSE OR FOR THE AMOUNT OF ANY JUDGMENT, AWARD OR SETTLEMENT TO THE EXTENT THAT SUCH
EXCEEDS THE LIMIT OF INDEMNITY OF THIS POLICY.

THE INSURED HEREBY FURTHER ACKNOWLEDGES THAT THE INSURED IS AWARE THAT LEGAL DEFENSE
COSTS THAT ARE INCURRED SHALL BE APPLIED AGAINST THE RETENTION AMOUNT.




SIGNATURE:                                                                                  s
                                                    Must be signed by the applicant’ president,
                                                    general counsel or director of risk management (or
                                                    other officer responsible for such function)
TITLE:



DATE:



60947 (3/96)                                - 4-