Application For A Claims-Made And Reported Lawyers Professional Liability Policy
Click for details of the online application process.  
Firm Name * Zip *
Address * Phone *
City * Fax
County * E-mail *
State Effective Date *
 
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
*
*(000-00-0000)
*
* * *
*
Designation Code : E = Member/Employee of the Firm , OC = Of Counsel/Independent Contractor and F = Full Time, P = Part Time (20 hours or fewer per week)
*If an attorney is requesting part time rates please provide the date that this attorney last practiced law full time. / / . Also please be advised that this designation should include all hours worked as an attorney, including but not limited to billable hours, non-billable hours and time spent operating a part time law practice.
    Yes No
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.
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 years? If YES, complete the Claim Supplemental Application.
4 * After inquiry, are you or any attorney in your firm aware of any circumstances, incidents, acts or omissions that has 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.
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 DESIRED
Limit :  Limit : 
Defense Cost :  Defense Cost : 
Deductible :  Deductible : 
Premium :   
 
 
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 % Government-Federal and State %
Antitrust % Government-Local (Not Bond Work) %
Arbitration/Mediation % Immigration/Naturalization %
Business Transactions-Corporate and Commercial % International Law %
Business Transactions-Entertainment % Labor Law %
Civil Rights /Discrimination % PI/PD-Plaintiff * %
Collection / Bankruptcy % Insurance Defense %
Construction Law (Building Contracts) % Workers Compensation-Defense %
Consumer Claims % Workers Compensation-Plaintiff %
Business Organization :   Natural Resources/Oil & Gas %
Formation / Alteration and
Mergers / Acquisitions
% Trademark / Copyright %
Secured Transactions % Patent %
Administrative Law / Record Keeping % Real Estate %
Criminal % Securities Law  
Environmental Law % State or Federal (Both Exempt and Registered) %
Estate / Trust / Probate % Municipal Bonds %
Family Law % Taxation/Tax Opinions %
    *Total %

Bold indicates that a separate supplemental application is required.

*If any member of the firm handles or has handled a mass tort/class action/multiple plaintiff case please provide a narrative describing the mass tort/class action/multiple plaintiff case. Description should include the capacity in which any attorney in the firm was involved in the case, the size of the class, and the amount of money involved.

 

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: ANY PERSON WHO, KNOWINGLY OR WITH INTENT TO DEFRAUD OR TO FACILITATE A FRAUD AGAINST ANY INSURANCE COMPANY OR OTHER PERSON, SUBMITS AN APPLICATION OR FILES A CLAIM FOR INSURANCE CONTAINING FALSE, DECEPTIVE OR MISLEADING INFORMATION MAY BE GUILTY OF INSURANCE FRAUD.

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.

*Name   *Title  *Date

PLEASE NOTE THAT THE FOLLOWING SECTION ONLY APPLIES TO FIRMS WITH ONE OR TWO ATTORNEYS

There are many factors used by the company to evaluate an application for Lawyers Professional Liability Insurance. Such factors may include a law firm’s areas of practice, loss history, risk management and an insurance score.

An insurance score is developed from a mathematical model that weighs and measures credit information obtained from a number of sources including a consumer credit report. Credit information may include payment history, the number of collections, bankruptcies, outstanding debt, length of credit history, types of credit in use and the number of new applications for credit. These factors have been shown to correlate with insurance loss history.

You may be eligible for a premium discount based upon your insurance score. An insurance score will not result in a premium increase. The insurance score is also never the basis on which this company will accept or reject an application for an insurance policy.

If this is acceptable all members of the applicant firm must provide authorization.
(Please fill at least one set of details.)
1. Signature : Date :
  Print Name : Title :
2. Signature : Date :
  Print Name : Title :
If you do not wish to have your insurance score computed check here
 

These questions are not part of the application but would appreciate your responses.

Other Bar Association Memberships *
How did you hear about us? *