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Application For Claims Made and Reported Lawyers
Professional Liability Policy

 





Firm/Applicant Name

Business Phone with Area Code

Email Address

Principal Business Address
City, County, State, Zip

Business Fax with Area Code

Effective Date Requested

1.     Please list all attorneys practicing on behalf of your firm. Add an attachment if necessary.

Attorney Name

Social Security
Number

Years in
Private
Practice

Designation
Code
(See Choices
Below)

Current Legal
Malpractice
Insurance Carrier

Current Retroactive
Date

Designation Code: E = Member/Employee of the Firm, OC = Of Counsel/Independent Contractor and F = Full Time, P = Part Time (26 hours or fewer per week)


2.     Have any members of your firm been reprimanded, censured, suspended or disbarred within the past five (5) years? If YES, provide full details on your letterhead.  No Yes


3.     Have any Professional Liability Claim(s) or suit(s) been made against the applicant firm or any attorney(s) in the applicant firm or former attorney(s) in the applicant firm within the past five (5) years? If YES, complete the Claim Supplemental Application.  No Yes


4.     After inquiry, are you or any attorney in your firm aware of any circumstances, incidents, acts or omissions that have led to a
Professional Liability Claim that has not yet settled or which could lead to a Professional Liability Claim being made against your
firm? If YES, complete the Claim Supplemental Application  No Yes


5.     Please list the limit of liability and deductible currently carried and select the appropriate type of limit and deductible. Select the
limit and deductible requested.

CURRENT

Limit:
$  

 Defense Costs Part of the Limit Defense Costs Outside the Limit Don't Know

Deductible:

Per Claim

    Aggregate

    Loss Only

$

    $

    $

 

6.     Please provide the percentage of gross billable dollars allocated to each Area of Practice. Please round to the nearest whole
number. Total must equal 100%.

  Admiralty/Maritime

  Antitrust

  Business Transactions-Corporate & Commercial

  BUSINESS TRANSACTIONS-ENTERTAINMENT

  Civil Rights/Discrimination

  Collection/Bankruptcy

  Construction Law (Building Contracts)

  Consumer Claims

BUSINESS ORGANIZATION:

         Formation/Alteration and Mergers/Acquisitions

         Secured Transactions

         Administrative Law/Record Keeping

  Criminal

  Environmental Law

  Estate/Trust/Probate

  Family Law

USE OF BOLD IN THE ABOVE TABLE INDICATES THAT A SEPARATE SUPPLEMENTAL APPLICATION IS REQUIRED.
The applicant represents that the above statements are true and correct to the best of his or her knowledge and that no material or
relevant facts have been suppressed or misstated and agree that the policy, if issued, will be issued on the reliance of such
representations.

Applicant acknowledges a continuing obligation to report to us as soon as practicable any material changes in the facts or
statements above, and in each supplementary application, which applicant becomes aware after signing the application.

NOTICE TO APPLICANTS: Any person who knowingly and with the 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 and subjects such person to criminal and civil penalties.

Completion of this form does not bind coverage. Applicant’s acceptance of Company’s quotation is required prior to binding
coverage and policy issuance. It is agreed that this application shall be the basis of the contract of insurance should a policy be
issued and it will be attached to the policy.


Attach your Letterhead or any other additional files here:    


Name

Title

Date

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