Lawyers Professional Liability Insurance Application
INSTRUCTIONS: ALL
QUESTIONS MUST BE ANSWERED ACCURATELY AND COMPLETELY. IF A POLICY IS
ISSUED, THE COMPLETED APPLICATION AND SUPPLEMENTS WILL BE ATTACHED TO AND BECOME
PART OF THE POLICY.
Firm Name:
COVERAGE REQUESTED
1. Limits of Liability. Claims expenses are outside the limits of liability
in AR, ID, KS, LA, ME, MI, MO, NC, NY, VA and VT and only under certain
circumstances in AK, NJ, NM and SD. Refer to policy language.
$100,000/$300,000
$1,000,000/$1,000,000
$4,000,000/$4,000,000
$9,000,000/$9,000,000
$200,000/$600,000
$1,000,000/$2,000,000
$5,000,000/$5,000,000
$10,000,000/$10,000,000
$250,000/$500,000
$2,000,000/$2,000,000
$6,000,000/$6,000,000
$500,000/$500,000
$2,000,000/$4,000,000
$7,000,000/$7,000,000
$500,000/$1,000,000
$3,000,000/$3,000,000
$8,000,000/$8,000,000
2. Deductible Amount Requested. Amount will apply PER CLAIM and will
include claims expenses except in LA, NJ, NY and VA.
$1,000
$2,500
$4,000
$10,000
$20,000
$35,000
Other:
$
$2,000
$3,000
$5,000
$15,000
$25,000
$50,000
3. Other Deductible and Limit Options:
Annual Aggregate Deductible:
Currently Have
Interested in Quotation
Deductible Not Applicable Towards Claims Expenses:
Currently Have
Interested in Quotation
Claims Expenses Outside Limits of Liability:
Currently Have
Interested in Quotation
GENERAL INFORMATION
4. Name(s) of Legal Entity(ies) to be insured (as referenced on your
letterhead)
5. Your Primary Location (Street Address, City, State, Zip Code, County)
6. Phone 7. Fax Number
PLEASE ATTACH A COPY OF THE FIRMS LETTERHEAD FOR EACH OFFICE LOCATION.
8. Does your firm practice from any other office location(s)?
YesNo
(If yes, please complete the Additional Locations
Supplement.)
9. Date Applicant Firm Established:
10. Indicate your firm formation or legal status (check one):
Partnership
Professional
Corporation or Association
Limited Liability
Company or Partnership
Sole Proprietor
Association
Other:
11. Indicate the Firms gross revenue for the applicable fiscal year.
(If Firm is newly established, please advise best estimate for current
fiscal year only):
a. Estimate for current fiscal year $
b. Actual for immediate past fiscal year $
c. Actual for second previous fiscal year $
12. Do you have any single client(s) representing 20% or more of your
gross revenue? ...YesNo
If yes, please list.
13. Do you advertise?...YesNo
If yes, please indicate in which of the following media and include
a copy of the ad and/or transcript.
Yellow Pages
Fliers
Newspapers
Periodicals
Radio
Television
Internet
14. List all predecessor firm(s) of the applicant. This is defined as
a law firm or practice which has undergone dissolution and at least
50% of the owners, officers, partners, principals or shareholders of
the prior firm have joined the successor firm.
15. If you are a Sole Proprietor, have you made arrangements with another
attorney to handle your cases in the event of your extended absence
from your practice? ...YesNo
If yes, please provide the following concerning your back-up attorney:...NA
Name: Phone #:
City/State:
16. Is this a full-time, private practice of law? ...YesNo
17. Please list all attorneys associated with the Firm (including yourself)
by category, using the following position designations.
O = Owner/Officer/Shareholder S = Sole proprietor EA = Employed
practicing attorneys of the firm not otherwise designated
A = Associate practicing for the Firm OC = Of Counsel attorney
of the Firm P = Partner of the partnership
CA = Attorneys on contract or per diem RP = Retired partners of
the Firm
18. Does the Firm or any member of the Firm have any other law partner(s),
associated, employed or independently contracted attorney(s) other than
those named above? ...YesNo
If yes, please provide details of such relationships.
19. Does any member of the Firm act as a public defender, prosecuting
attorney, public official, an in-house attorney of any corporation or
governmental agency, or an independent contractor or Of Counsel to another
firm?...YesNo
If yes, please provide details.
20. Provide the total number of non-attorney staff serving as:
21. Does any attorney or non-attorney member of your Firm provide professional
services as an accountant,insurance agent or broker, investment adviser,
real estate agent or broker or securities agent or broker?...YesNo
If yes, please indicate members name, type of services provided, percentage
of time spent, under which name these services are provided, professional
liability carrier, limit of liability and copy of letterhead used.
22. Complete the following chart based upon the Firms gross revenue
for each category. The total must equal 100%.
If Firm is newly established, please provide best estimate.
If the Firm practices in any area(s) above with a numerical notation(s),
complete the associated Supplement so indicated below.
(2) Copyright Patent Trademark (4)
Real Estate
(6) Plaintiff Litigation
23. Has any member or former member of the Firm, at any time in the
past six (6) years, provided any legal services or served as a fiduciary,
committee member, director, officer, partner or employee of any Financial
Institution? ...YesNo
24. Has any member or former member of the Firm, at any time in the
past six (6) years, provided legal services:
a. To issuers, underwriters or affiliates thereof, with respect to the
issuance, offering or sale of securities? ...YesNo
b. In any way related to the formation, syndication, promotion or management
of any limited partnerships? ...YesNo
25. Does the Firm provide any services in connection with any pre-paid
legal services plan?...YesNo
If yes, please provide details.
RISK MANAGEMENT
26. Concerning your docket control and/or calendjudahng system(s):
a. Does the Firm regularly make use of these system(s) with at least
two independent date controls for each item?...YesNo
b. Indicate all types regularly utilized:
Computer
Tickler
System
Two Calendar System
Perpetual
Calendar Daytimer
Pocket Calendar
Other (Describe):
c. Are two separate individuals entering dates into different systems
for the same matter?...YesNo
d. Are the entries in different systems being cross-checked on a regular
basis?...YesNo
e. Who is calculating the follow-up dates to be entered into the systems?
f. If the answer to the above is not an attorney, does an attorney regularly
review them to make sure the proper date has been selected? ...YesNo
g. If you are a Sole Practitioner with no employees, who is providing
back-up for these systems in the event of your extended absence?
NA
h. Do you have a procedure in place to ensure that calendar entries
are being reviewed and responded to for any attorney who is absent from
the office for an extended period?...YesNo
27. Concerning your conflict of interest avoidance system(s) and procedure:
a. Does the Firm regularly make use of a conflict of interest avoidance
procedure when accepting new clients or a new matter from existing clients?
...YesNo
b. Indicate method(s) used to achieve conflict checks:
Oral/Memory
Computer
Index File
Conflict
Committee
Perpetual
Calendar Client
Lists
Other (Describe):
c. Does the Firm disclose to clients, in writing, all actual or potential
conflicts of interest?...YesNo
d. Upon disclosure of actual or potential conflicts, do you or your
Firm always obtain written consent to perform ongoing legal services
or decline further representation in writing? ...YesNo
e. Does this procedure capture attorney-client relationships established
by predecessor, merged or acquired firms?
NA ...YesNo
28. Has the Firm or any present or former member of the Firm or predecessor
firm provided legal professional services to clients or referred clients
to any business organization in which ANY FIRM MEMBER OR SPOUSE ever:
a. Served as a director, officer, partner, trustee or fiduciary (such
as an administrator, conservator, executor, guardian, trustee, receiver,
escrow agent)?...YesNo
b. Owned an equity or financial interest?...YesNo
If yes to any part of Question 28 above, please
complete the Outside Interest and/or Trustee Supplement(s) as applicable.
29. Do you regularly make use of written fee or retainer agreements
and/or engagement letters when accepting work? ...YesNo
If no, please explain how you eliminate misunderstandings about the
scope and cost of services being provided.
30. Do you regularly make use of written declination or non-engagement
letters when declining work?...YesNo
If no, please explain how you eliminate misunderstandings about representation.
31. Within the past five (5) years, have you sued to collect fees or
threatened to do so? ...YesNo
If yes, please indicate number
and advise what steps
you are taking to prevent countersuits for malpractice.
32. What percentage of your accounts receivable are over ninety (90)
days past due?
If more than 30%, what steps are being taken to
reduce this percentage?
PRIOR COVERAGE AND CLAIMS HISTORY
33. In the past five (5) years, has any professional liability claim
or suit ever been made against the Firm or any predecessor firm or any
current or former member of the Firm or predecessor firm?...YesNo
If yes, please indicate how many
and complete a separate
Supplemental Claim Form for each claim.
34. Does any attorney for whom coverage is sought know of any incident,
act, error or omission that could result in a claim or suit against
the Firm or any predecessor firm or any of the current or former members
of the Firm?...YesNo
If yes, please indicate how many
and complete a separate Supplemental Claim Form for each incident.
35. Has any attorney for whom coverage is sought been refused admission
to practice, disbarred, suspended, reprimanded, sanctioned, or held
in contempt by any court, administrative agency or regulatory body or
been the subject of a disciplinary complaint made to any of the aforementioned
entities?...YesNo
If yes, please provide details.
36. List the Lawyers Professional Liability Insurance Coverage carried
during the past five (5) years, including any periods without coverage.
Also, if currently uninsured, please check this box:
37. Inception date of firms first claims made policy, maintained without
interruption to date:
38. Does your current policy have a prior acts limitation or retroactive
date applicable to the Firm or any individual attorney?...YesNo
If yes, please indicate date and to whom it applies if other than the
Firm:
39. Does your current policy contain any exclusions or coverage limitations
tailored specifically to your Firm?...YesNo
If yes, please describe and attach a copy of the endorsement:
40. In the past five (5) years, has the Firm or any Firm member ever
had professional liability insurance or similar insurance declined,
cancelled or non-renewed?...YesNo
(Missouri residents, do not answer)
If yes, please explain.
41. Has the Firm or any attorney for whom coverage is sought ever purchased
an extended reporting period endorsement?...YesNo
If yes, please provide details.
ARKANSAS: Any person
who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
COLORADO: It is unlawful
to knowingly provide false, incomplete, or misleading facts or information
to an insurance company for the
purpose of defrauding or attempting to defraud the company. Penalties
may include imprisonment, fines, denial of insurance, and civil
damages. Any insurance company or agent of an insurance company who
knowingly provides false, incomplete, or misleading facts or
information to a policyholder or claimant for the purpose of defrauding
or attempting to defraud the policyholder or claimant with regard
to a settlement or award payable from insurance proceeds shall be reported
to the Colorado division of insurance within the department
of regulatory agencies.
DISTRICT OF COLUMBIA:
WARNING: It is a crime to provide false or misleading
information to an insurer for the purpose of
defrauding the insurer or any other person. Penalties include imprisonment
and/or fines. In addition, an insurer may deny insurance
benefits if false information materially related to a claim was provided
by the applicant.
FLORIDA: Any person
who knowingly and with intent to injure, defraud, or deceive any insurer
files a statement of claim or an
application containing any false, incomplete, or misleading information
is guilty of a felony of the third degree.
HAWAII: For your
protection, Hawaii law requires you to be informed that presenting a
fraudulent claim for payment of a loss or benefit
is a crime punishable by fines or imprisonment, or both.
KENTUCKY: Any person
who knowingly and with intent to defraud any insurance company or other
person files an application for
insurance 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.
LOUISIANA: Any person
who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or knowingly presents
false information in an application for insurance is guilty of a crime
and may be subject to fines and confinement in prison.
MAINE: It is a crime
to knowingly provide false, incomplete or misleading information to
an insurance company for the purpose of
defrauding the company. Penalties may include imprisonment, fines or
a denial of insurance benefits.
MINNESOTA: A PERSON
WHO SUBMITS AN APPLICATION OR FILES A CLAIM WITH INTENT TO DEFRAUD OR
HELPS
COMMIT A FRAUD AGAINST AN INSURER IS GUILTY OF A CRIME.
NEW JERSEY: Any person
who includes any false or misleading information on an application for
an insurance policy is subject to
criminal and civil penalties.
NEW MEXICO: ANY PERSON
WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A
LOSS OR
BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR
INSURANCE IS GUILTY OF A CRIME
AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES.
NEW YORK (Non Auto):
Any person who knowingly and with 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 shall also be subject to a
civil penalty not to exceed five thousand dollars and the stated value
of the claim for each such violation.
OHIO: ANY PERSON
WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD
AGAINST AN
INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE
OR DECEPTIVE STATEMENT IS GUILTY OF
INSURANCE FRAUD.
OKLAHOMA: WARNING:
Any person who knowingly, and with intent to injure, defraud or deceive
any insurer, makes any claim for the
proceeds of an insurance policy containing any false, incomplete or
misleading information is guilty of a felony.
OREGON: Any person
who knowingly and with intent to defraud or solicit another to defraud
the insurer by submitting an application
containing a false statement as to any material fact, may be violating
state law.
PENNSYLVANIA: ANY
PERSON WHO KNOWINGLY AND WITH 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
THE PERSON TO CRIMINAL AND
CIVIL PENALTIES.
PUERTO RICO FRAUD WARNING:
Any person who knowingly and with the intent to
defraud, presents false information in an
insurance request form, or who presents, helps or has presented a fraudulent
claim for the payment of a loss or other benefit, or
presents more than one claim for the same damage or loss, will incur
a felony, and upon conviction will be penalized for each violation
with a fine of no less than five thousand dollars ($5,000) nor more
than ten thousand dollars ($10,000); or imprisonment for a fixed term
of three (3) years, or both penalties. If aggravated circumstances prevail,
the fixed established imprisonment may be increased to a
maximum of five (5) years; if attenuating circumstances prevail, it
may be reduced to a minimum of two (2) years.
TENNESSEE (Non WC):
IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE
OR MISLEADING INFORMATION TO
AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES
INCLUDE IMPRISONMENT,
FINES AND DENIAL OF INSURANCE BENEFITS.
VERMONT: Any person
who knowingly and with intent to defraud any insurance company or another
person files an application for
insurance containing any materially false information or conceals for
the purpose of misleading information concerning any fact material
thereto, may be committing a crime, subjecting the person to criminal
and civil penalties.
VIRGINIA: It is a
crime to knowingly provide false, incomplete or misleading information
to an insurance company for the purpose of
defrauding the company. Penalties include imprisonment, fines and denial
of insurance benefits.
WASHINGTON: It is
a crime to knowingly provide false, incomplete, or misleading information
to an insurance company for the
purpose of defrauding the company. Penalties include imprisonment, fines,
and denial of insurance benefits.
WEST VIRGINIA: Any
person who knowingly presents a false or fraudulent claim for payment
of a loss or benefit or knowingly presents
false information in an application for insurance is guilty of a crime
and may be subject to fines and confinement in prison.
ALL OTHER STATES:
Any person who knowingly and with intent to defraud any insurance company
or another person files an
application for insurance 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 the person to criminal and civil penalties.
Not applicable in Nebraska.
YOUR SIGNATURE AND AUTHORIZATION
The undersigned authorized representative of the firm, or individual
if this application is for an individual, agrees to all to the following:
The statements and representations made in this application are true
and complete and, if issued, this application and any
supplements will be attached to and made a part of the policy.
If the information supplied in this application changes between the
date of the application and the effective date of any insurance
policy issued by Travelers in response to this application, you will
immediately notify us of such changes, and we may withdraw or
modify any outstanding quotation or agreement to bind coverage.
Travelers is authorized to make an investigation and inquiry in connection
with this application.
Travelers is not bound or obligated to issue any insurance policy or
to provide the insurance requested in this application.
Important Note: This
application is not a representation that coverage does or does not exist
for any particular claim or loss, or type of
claim or loss, under any insurance policy issued by Travelers. Whether
coverage exists or does not exist for any particular claim or loss
under any such policy depends on the facts and circumstances involved
in the claim or loss and all applicable wording of the policy
actually issued.
