Eligibility Declaration

Insured Information

• First Name
• Last Name
• Address
•  
• Phone
• Email

1. Are you a current financial member of the AFCC?

Yes
No

2. Have you and/or your business ever been subject to a professional indemnity or public & products liability claim?

Yes
No

3. Are you aware of any matter that has the potential to result in a claim against you and/or your business?

Yes
No