PLEASE NOTE:  This is a sample general form only.  It is not specific to any particular jurisdiction.  It is not designed to be used without first obtaining legal review.  This form will often require updating and revision before it can be effectively implemented and legal counsel should be consulted to ensure this general form complies with all applicable state and federal laws in a given jurisdiction.  Insurance Specialty Group, LLC and Wood, Smith, Henning & Berman, LLP disclaims any and all liability arising out of or related in any way to use of this sample form.