Short Form New Business Application Instructions: a. All questions must be answered. Please indicate if the answer to any question is NONE or NOT APPLICABLE. b. If space is insufficient to answer any question fully, attach a separate sheet. c. Application must be completed, signed and dated by an owner, officer or partner of the law firm. d. Please attach a sample of the law firm s current letterhead to this application. A. LAW FIRM INFORMATION List additional locations on the law firm s letterhead 1. Law Firm Name: 2. Contact/Administrator Name: Email Address: Your email address will never be sold. It will be used to send you important messages. 3. Contact Telephone No.: Contact Fax No.: 4. Practice Address: Street City State County Zip 5. Billing Address: (If different than practice address) 6. Law Firm Web Address: 7. Current Firm Established: B. GENERAL INFORMATION 1. Has the firm purchased professional liability insurance in the past 5 years?... If yes, please complete the following: Insurer Coverage s Limits of Liability Limit Type CEOL/CEIL Deductible Aggergate Deductible? Loss Only Deductible? Expiring Premium Please submit a copy of the current declarations page, all endorsements and any attachments indicating the retroactive dates for the law firm as well as all insured lawyers. 2. What was the law firm s gross revenue in the last completed fiscal year? 3. Estimate the law firm s annualized gross revenue for the current fiscal year: 4. In the past 12 months, what was the single highest case value or transaction the law firm handled (not in terms of revenue to the firm, but of the case or transaction itself)? 5. In the past 12 months, what was the average case value or transaction handled by the firm? 6. What percentage of the law firm s billings are over 90 days past due? 7. In the past 12 months, how many suits for fees has the law firm filed? 1 of 4
C. AREAS OF PRACTICE (Please round to the nearest whole percent.) 1. Please provide the percentage of hours worked in the areas of practice below during the last 12 months: Admiralty/Marine.- Plaintiff %.- Defense % Anti-Trust/Trade Regulation % Arbitration/Mediation % Aviation % Banking/Financial Institutions* % Bankruptcy % Civil Rights/Discrimination % (non-employment) Collections/Repossession (no foreclosures)* - Commercial % - Consumer % Construction/Building Contracts % Communications/FCC % Corporate/Business Transactions.- Administrative %.- Formation/Alteration % - General Contracts % - Mergers/Acquisitions % - Secured Transactions % Consumer Claims (no class action) % Criminal Defense % Defense.- Bodily Injury/Personal Injury %.- Class Action* %.- Insurance Company Defense* %.- Insurance Defense* %.- General/Civil Litigation %.- Medical Malpractice %.- Workers Compensation % Divorce - $1M or less in assets % - Over $1M in assets % Elder Law % Employee Benefit Plans/ERISA % Entertainment/Sports* % Environmental.- Non-Regulatory %.- Regulatory % Estates/Wills/Trust/Probate*.- Less than $1M %.- $1M - $5M %.- Over $5M % Family/Juvenile no divorce % Healthcare % Immigration % Intellectual Property* - Trademark % - Copyright % - Patent % International/Foreign Law % Investment Counseling/Money Management % Labor/Employment - Employee % - Management % - Union % Municipal/Government - General (no bonds) % - Finance or Bonds % - Zoning and Planning % Oil/Gas/Mineral Rights % Plaintiff* - Bodily Injury/Personal Injury % - Class Action* % - General/Civil Litigation % - Medical Malpractice % - Workers Compensation % Public Utilities % Real Estate* - Abstract/Title % - Commercial % - Escrow Agent % - Foreclosure/Loan Modification* % - Residential % - Syndication/Development % Securities* % Social Security % Tax. - Individual % - Business % - Opinions* % Other provide a written description % Total (must equal 100%) % * Please complete the applicable Area of Practice supplement for those bolded and marked with an asterisk. 2. In the past 5 years, has the law firm or any lawyer in the law firm provided services in any of the following areas: Securities/Bonds?... Class Action/Mass Tort?... Intellectual Property?... Entertainment?... Marijuana/Dispensary Law?... If you answered yes to any of the above, please complete the applicable Area of Practice Supplemental Application. (Provide a narrative for Marijuana/Dispensary Law.) 2 of 4
D. DISCIPLINE AND CLAIMS INFORMATION 1. Has any lawyer in the law firm currently or in the past 5 years: Participated in an impaired lawyer program, either on a voluntary or involuntary basis?... Been refused admission to practice, disbarred or suspended from practice; been reprimanded, sanctioned or disciplined by any court or administrative agency, to include grievances, or are any such proceedings currently in progress?... If yes to any of the above, provide a brief explanation on the firm letterhead, including any supporting documentation from the appropriate court or agency. 2. After inquiry of all lawyers and employees of the law firm, including independent contractors, Of Counsel and any other affiliated lawyers, is any such person aware of: A professional liability claim made in the past 5 years (either still open or closed)?... An act or omission that might reasonably be expected to be the basis of a claim?... If yes, please complete an Incident/Claims Supplement form for each claim, suit, or incident. E. INTERNAL PROCEDURES 1. Docket Controls (indicate with a check all the controls the firm has in place): q Single Calendar q Two Independent Calendars q Computer q Tickler q Master Listing Other (please describe): 2. Are at least two individuals maintaining the docket controls?... 3. How often are the docket controls cross checked? q Daily q Weekly q Monthly q Quarterly Other (please describe): 4. Conflict of Interest Systems (indicate with a check all systems the firm has in place): q Computer q Index File q Conflict Committee Other (please describe): 5. How often is the conflict of interest system updated? q Daily q Weekly q Monthly 6. Client Communication: Does the firm require the use of engagement letters for all matters undertaken by the firm?... Are declination or non-engagement letters issued on matters declined by the firm?... Are scope of service letters or fee arrangement letters utilized when new matters are accepted by the firm for existing clients?... 7. Has the firm acquired or opened a new location in the last 12 months?... If yes, please provide the location and brief explanation that includes the services provided, attorneys, staff and purpose of that office on a copy of the firm s letterhead. 3 of 4
E. INTERNAL PROCEDURES (cont.) 8. Does any lawyer in the firm: Serve as a director, officer, trustee, owner or partner of, exercise any fiduciary control or hold any equity interest in any organization other than the law firm?... Own, manage, or have any financial control or equity interest in any for-profit business of a client of the law firm?... Provide legal services in exchange for any equity interest in a client of the law firm?... Act as an employee of any organization other than the law firm?... If you answered yes to any of the above, complete the Outside Interest Supplement. 9. Does any single client make up more than 25% of the law firm s annual billings?... If yes, please provide the name of each client and the actual percentage. If a position or equity interest held, complete the Outside Interest Supplement. F. Law firm tax identification number and signature Federal Employer Identification Number (FEIN) or Taxpayer Identification Number: By signing this application, I certify and attest that the statements, information, and answers provided in this application and in its supplements and attachments are true and accurate. I understand that Professional Solutions Insurance Company (PSIC) shall rely upon the statements, information, and answers provided to determine whether to accept this application for insurance and, if the application is accepted, to determine at what rate to insure. For residents of all states except CO and PA: Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance containing anymaterially false information or conceals, for the purpose of misleading, information concerning any fact material thereto or knowingly helps with intent to defraud, commits a fraudulent insurance act, which may be a crime and may subject the person to criminal and civil penalties. 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. 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 such person to criminal and civil penalties. Professional liability insurance offered through Attorney Shield is underwritten by Professional Solutions Insurance Company (doing business in California as PSIC Insurance Company). Signature of Owner, Partner or Officer Soliciting Agent Agency Name PSIC Professional Solutions INSURANCE COMPANY 14001 University Avenue Clive, Iowa 50325-8258 Questions: Phone: 800-510-8240 4 of 4
Individual Lawyer and Office Staff Supplement The policy limits of liability are shared by all Insured s under this policy. 1. List all lawyers practicing on behalf of the law firm. Attach a separate sheet for additional lawyers. Lawyer s Name Position O Owner, P Partner E Employee OC Of Counsel IC Ind. Contractor Hours worked annually Primary State Bar # States Admitted (state abbreviation) First Admitted of Hire Retroactive Total CE hours in the past 12 months CE hours specific to Ethics 2. Provide the name of the owner or partner authorized to make changes to the policy: 3. Enter the total number of lawyers and staff in each category: Lawyers Paralegals/Law Clerks Clerical/Administration Investigators/Abstractors Other Provide number and titles 4. In the last 12 months, how many lawyers have left the law firm? Approximately how many lawyers will be added in the next 12 months? For residents of all states except CO: 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 or knowingly helps with intent to defraud, commits a fraudulent insurance act, which may be a crime and may subject the person to criminal and civil penalties. 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. Professional liability insurance offered through Attorney Shield is underwritten by Professional Solutions Insurance Company (doing business in California as PSIC Insurance Company). Signature of Owner, Partner or Officer Soliciting Agent Agency Name 2016 PSIC NFL 9826-162009