Legalis Consilium EMPLOYMENT DATES
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1 Legalis Consilium NEW LAWYER SUPPLEMENT FOR LAWYERS PROFESSIONAL LIABILITY INSURANCE THIS APPLICATION IS FOR A CLAIMS MADE AND REPORTED INSURANCE POLICY 1. Firm: Policy Number: 2. Complete the following chart for the new Lawyer and please attach current CV/resume. Codes: O Officers, Directors or Shareholders of the Firm who are licensed attorneys P Partner / Member E Employed Lawyers (must be an employee of the Firm) C Of Counsel attorneys for whom coverage is desired A Associate for whom coverage is desired IC Independent Contractor attorney for whom coverage is desired NEW LAWYER S NAME CODE(S) DATE ADMITTED TO BAR DATE JOINED FIRM EXPECTED BILLABLE HOURS 3. New Lawyer s Prior Firm and Professional Liability Insurance History for the past three (3) years: NAME OF PRIOR FIRM EMPLOYMENT DATES PL CARRIER LIMIT OF LIABILITY POLICY PERIOD 4. Is the new Lawyer covered under an Extended Reporting Period Endorsement? Yes No 5. Is the Lawyer identified in question 3 above aware of any Professional Liability claims or suits made against him or her in the past five (5) years or any circumstances, acts, errors or omissions that could result in a professional liability claim or suit? Yes No If YES, please complete a Supplemental Claim Application for each claim or incident. 6. Has the new Lawyer been the subject of a reprimand or disciplinary action or refused admission to the bar by any bar association, court or administrative agency in the past five (5) years? Yes No If YES, please complete a Supplemental Claim Application for each claim or incident. 7. Has the new Lawyer had or does the new Lawyer currently have equity interest in any past or present client? If YES, please complete the attached Addendum 1. Yes No SRA Page 1 of 8
2 NOTICE: It is agreed by all concerned that if any of the proposed Insured Persons is responsible for or has knowledge of any Wrongful Act, fact, circumstance, or situation which s(he) has reason to suppose might result in a future Claim, whether or not described above, any Claim subsequently emanating therefrom shall be excluded from coverage under the proposed insurance. NOTICE: The undersigned Applicant represents that the statements set forth in this application and its attachments and other materials submitted to the Insurer are true and correct. Signing of this application does not bind the Applicant or the Insurer. In the event there is any material change in the answers to the questions herein prior to the issuance date of the Policy that would render this application form inaccurate or incomplete, the Applicant will notify the Insurer in writing, and, if necessary, any outstanding quotation may be modified or withdrawn. The Principal below declares and warrants that he / she has the authority to sign this letter on behalf of the Firm. Print Name: Signature: Date: Title: SRA Page 2 of 8
3 FRAUD WARNINGS GENERAL: 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. The fraud warnings listed below are applicable in the following states: AL, AK, AZ, AR, CA, CO, DE, DC, FL, HI, ID, IN, KY, LA, ME, MD, MA, MN, NE, NH, NJ, NM, NY, OH, OK, OR, PA, TN, TX, VT, VA, WA or WV. If you are located in one of these states, please take time to review the appropriate warning prior to submitting your claim. ALABAMA: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines, or confinement in prison, or any combination thereof. ALASKA: Any person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information may be prosecuted under state law. ARIZONA: For your protection Arizona law requires the following statement to appear on this form: Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. 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. CALIFORNIA: For your protection, California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state 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. SRA Page 3 of 8
4 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. DELAWARE: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony. 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. IDAHO: Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony. INDIANA: A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or misleading information commits a felony. KENTUCKY: Any person who knowingly and with intent to defraud any insurance company or other person files a 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. SRA Page 4 of 8
5 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. MARYLAND: Any person who knowingly and wilfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and wilfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. MASSACHUSETTS: Any person who knowingly and with intent to defraud any insurance company or another 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, may be committing a fraudulent insurance act, which may be a crime and may subject the person to criminal and civil penalties. MINNESOTA: A person who files a claim with intent to defraud, or helps commit a fraud against an insurer, is guilty of a crime. NEBRASKA: Any person who knowingly and with intent to defraud any insurance company or another 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, may be committing a fraudulent insurance act, which may be a crime and may subject the person to criminal and civil penalties. NEW HAMPSHIRE: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20. NEW JERSEY: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. SRA Page 5 of 8
6 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: 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 an insurer: (1) by submitting an application, or (2) by filing a claim containing a false statement as to any material fact thereto, may be committing a fraudulent insurance act, which may be a crime and may subject the person to criminal and civil penalties. 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 act, which is a crime and subjects such person to criminal and civil penalties. TENNESSEE: 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. TEXAS: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. SRA Page 6 of 8
7 VERMONT: Any person who knowingly and with intent to defraud any insurance company or another 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, may be committing a fraudulent insurance act, which may be a crime and may subject 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 may include imprisonment, fines, or 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. SRA Page 7 of 8
8 Addendum 1 Outside Interests Table 1. Lawyer Name Client Name Nature of Business Professional Services Position Held % Equity Interest Annual % of Firm Gross Billings SRA Page 8 of 8
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GARAGE RENEWAL APPLICATION
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Not for Profit Directors & Officers Insurance Application
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Professional Liability Errors and Omissions Insurance Application
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PIPELINE CONSTRUCTION SUPPLEMENTAL APPLICATION
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MEDICAL/SICKNESS CLAIM FORM
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Miscellaneous Professional Liability Application
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Evanston Insurance Company Markel American Insurance Company Markel Insurance Company
Evanston Insurance Company Markel American Insurance Company Markel Insurance Company FOR PROFIT MANAGEMENT LIABILITY RENEWAL APPLICATION BY COMPLETING THIS APPLICATION THE APPLICANT IS APPLYING FOR COVERAGE
CONSTABLE PROFESSIONAL LIABILITY APPLICATION
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OFF PREMISES LIQUOR LIABILITY APPLICATION
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Roofing Supplemental Application
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GROUP SHORT-TERM DISABILITY STATEMENT OF EMPLOYEE
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CLAIM FORM. DATE OF BIRTH: 3. PATIENT'S NAME & ADDRESS- IF ADDRESS IS NEW, PLEASE CHECK BOX r PHONE: ( )
PRIMERICA LIFE INSURANCE COMPANY as Administered by Senior Health Ins. Co. of Pennsylvania Home Office: Boston, MA P.O. Box 64913 St. Paul, MN 55164 Telephone: 1-877-451-5824 CLAIM FORM The patient or
SUPPLEMENTAL APPLICATION FOR PROFESSIONAL EMPLOYER ORGANIZATIONS AND TEMP FIRMS
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BUSINESS AUTO APPLICATION
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LAW FIRM PROFESSIONAL LIABILITY APPLICATION
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Trip Delay. 3. Please upload the completed and signed claim form and all required documents to myclaimsagent.com or mail to:
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ExecPro Proposal Form for Fiduciary Liability Insurance
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Applicant s Name: Location: Please complete this section for swimming pools, spas, whirlpools and saunas
Swimming Pools/Beaches Supplemental Application TO BE USED WITH COMMERCIAL GENERAL LIABILITY APPLICATION (ACORD 125) All questions must be answered in full. Application must be signed and dated by the
Convenience Store Application
Convenience Store Application All questions must be answered in full. Application must be signed and dated by the applicant. Applicant s Name Agent Applicant Mailing Address Applicant s Phone Number Web
PERSONAL INLAND MARINE POLICY APPLICATION
Scottsdale Insurance Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Adm. Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258 Scottsdale Surplus Lines Insurance Company Adm.
Feed Manufacturing Supplemental Application
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