Please note: For any return that is prepared while you wait, payment is expected at the time of completion.

I authorize Rogers Medical, Ltd and each applicable health care provider to disclose health-related information and medical records about me to any person or entity (including,

If you have answered ‘Yes’ to any of the questions above, please provide details below.  Use an additional page if needed.  We reserve 

Did you lease a car which you used for business...☐ Yes ☐ No lf "Yes", provide (1) fair market value or capitalized cost of the car on the lst day of the lease or

Did you drive your car for work (non‐commuting)  in this business?  If yes, please fill out the 

Date of Sale (Must provide copy of settlement/closing statement) Total Miles Driven for Personal. Total Miles Driven for Rental Activity Is this

If yes, please specify the percentage of time you spend with hazardous materials work or solvents in your main occupation, and also provide details of the hazardous materials:.

Insured's vehicle - If you are claiming under your own Norwich Union policy for damage to your vehicle please complete the following: Is your vehicle mobile. Continued yes no yes no

If Yes, please provide full details, including copies of any such agreements. a) Do you have current Professional Indemnity Insurance in force? If Yes, please advise the following