LAWYERS PROFESSIONAL LIABILITY INSURANCE NEW BUSINESS APPLICATION THE POLICY FOR WHICH THIS APPLICATION IS MADE IS WRITTEN ON A CLAIMS MADE AND REPORTED BASIS. TO BE COVERED, A CLAIM MUST BE FIRST MADE AGAINST THE APPLICANT DURING THE POLICY PERIOD AND REPORTED TO THE UNDERWRITER DURING THE POLICY PERIOD OR SIXTY (60) DAYS THEREAFTER, OR FIRSTT MADE AGAINST THE APPLICANT AND REPORTED TO THE UNDERWRITER DURING AN EXTENDED REPORTING PERIOD, IF APPLICABLE. THE LIMIT OF LIABILITY AVAILABLE TO PAY JUDGMENTS OR SETTLEMENTS WILL BE REDUCED AND MAY BE EXHAUSTED BY PAYMENT OF CLAIM EXPENSES. DEDUCTIBLES APPLY TO JUDGMENTS, SETTLEMENTS AND CLAIM EXPENSES. PLEASE READ THE ENTIRE APPLICATION CAREFULLY BEFORE SIGNING AND CONTACT YOUR PRODUCER WITH ANY QUESTIONS. Instructions: 1. Complete the appropriate area of practice supplement if Applicant provides services in the following areas: Bankruptcy Real Estate Intellectual Property Collections Estate Probate & Trust Plaintiff Litigation Foreclosure Entertainment Defense Litigation Financial Institutionss Tax Opinions Securities or Bonds 2. Complete any applicable supplement as indicated by the answers to the Application: Claim Outside interest 3. Applicants must complete an Individual Lawyers Supplement in addition to the Application. A. ACCOUNT INFORMATION 1. Applicant Name Doing Business As Principle State of Operations 2. Mailing Address Street: City: County: State: Website Address: Zip: 3. Risk Manager or Contact Person Name/Title: Email Address: Telephone Number: 4. Year firm was established 5. Organization Individual Corporation Partnership Joint Venture LLC Other: 6. List all states where the Applicant is operating and providingg services: AG EO 8004 LP - 11-14 Page 1 of 11
7. Does the Applicant have other locations? If, please complete the following for each location: Central Systems City/State # Lawyers Centrally Managed and Procedures 8. Does the Applicant anticipate any material changes within the firm in the next 24 months? If, do the changes include any of the following? Changes in areas of practice Additional offices Adding group or groups of attorneys Loss of group or groups of attorneys Dissolution Merger or acquisition of another firm Change in corporate structure or management Bankruptcy or other financial reorganization 9. Does the Applicant own, operate or manage any business or facilities other than the operations described in this Application? If, please provide details, including name of entity and the Applicant s ownership interest/management role: B. CURRENT AND REQUESTED COVERAGE Please note that requested coverage is not automatically provided. The policy, if issued, will determine the actual coverage. 10. Please indicate below what coverages, limits, and deductibles are being requested: Coverages Requested Limit of Liability Requested Deductible Requested Lawyers Professional Liability $ $ 11. Does the Applicant currently have a prior acts date or retroactive date applicable to the entire firm? If, indicate the date on current declarations page: 12. What year did the Applicant first obtain professional liability coverage? 13. Has the Applicant maintained coverage continuously since that date? 14. Does the Applicant currently have any endorsements attached to the policy restricting coverage to the firm? If, please attach a copy to this Application. AG EO 8004 LP - 11-14 Page 2 of 11
15. Please list all primary and excess lawyers professional liability insurance policies carried during the past five (5) years, include any period without coverage. Policy Period Insurer Limits of Liability Deductible Premium Number of Lawyers $ $ Primary Excess $ $ Primary Excess $ $ Primary Excess $ $ Primary Excess $ $ Primary Excess 16. Has the Applicant ever purchased an extended reporting period endorsement? If, please provide details: 17. MISSOURI RESIDENTS DO NOT ANSWER THIS QUESTION. Has any professional liability insurer ever cancelled, declined or reduced coverage (i.e. reduced limits, restricted coverage, surcharged rates or refused renewal) for the Applicant or any lawyer at the Applicant s firm? If, please provide details: AG EO 8004 LP - 11-14 Page 3 of 11
C. FINANCIAL & EXPOSURE DETAILS 18. Please identify the Applicant s area(s) of practice based on the Applicant s gross billings. Please use whole numbers. Total must equal 100 This Area of Practice Current Breakdown within Particular Area of Law Year Admirality/Maritime Plaintiff Defense Other Alternative Dispute Resolution Antitrust Plaintiff Defense Other Appellate Business Formation and Alteration Formation/ Mergers & Dissolution Acquisitions Other Private Business Transactions Public Corporations/ Corporate & Commercial Corporation Individuals Other Civil Rights & Discrimination Plaintiff Defense Other Bankruptcy/Collection/Foreclosure Creditor Debtor Court Appointed Trustee Business & Commercial Litigation Plaintiff Defense Construction Law/Building Contracts Plaintiff Defense Transactional Consumer Claims/Administrative Law Criminal Law Employee Benefits Entertainment Law Environmental Law Plaintiff Defense Other Estate, Probate & Trust Estate Planning Trust Administration Other Family Law Divorce Adoption Other Federal, State & Local Government General or Financial Advice Defense Other Financial Institutions General Regulatory Counsel Counsel Other General Civil Litigation Plaintiff Defense Health Care Plaintiff Defense Other Immigration & Naturalization Insurance Defense Litigation Coverage Other Intellectual Property Labor & Employment Management Union/Labor Other Natural Resources/Oil & Gas Real Estate Commercial Residential Other Securities/Bonds Taxation/Tax Opinions Personal Corporate Other Workers Compensation Employer Employee Other (describe): AG EO 8004 LP - 11-14 Page 4 of 11
19. Please provide the following financial information for the Applicant: Year Ending: (MM/DD/YYYY) Gross Revenue Latest Fiscal Year $ $ 1 st Prior Fiscal Year Gross Revenues 2 nd Prior Fiscal Year Net Income $ $ $ $ Net Revenue 20. Are any of the firm s accounts receivable more than 90 days past due? If, what percentage of accounts receivable are past due? 21. Is any of the Applicant s work performed in jurisdictions outside of the United States? If, identify the type of work done and the jurisdiction: 22. Is any of the Applicant s work: a. Performed in jurisdictions outside of the states where the Applicant has office locations? b. Performed for clients who are located outside the United States? If to any of the above, identify the type of work done and the jurisdiction: 23. In the last five (5) years, has any of the Applicant s work involved: a. Representation of plaintiffs in class action or mass tort litigation? b. Issuance of securities or compliance with laws and regulations governing securities? c. Intellectual property? If to any of the above, complete the applicable supplement. 24. List the total number of: a. Current lawyers (complete the Individual Lawyer(s) Supplement for each lawyer in the firm): b. Lawyers leaving the firm in the last twelve (12) months: c. Lawyers joining the firm in the last twelve (12) months: d. Paralegals and law clerks: e. Investigators: f. Other non-lawyer staff: 25. Does the Applicant share any of the following with any firm or lawyer(s) who is/are not members of the Applicant firm? a. Office space b. Secretary/receptionist c. Other employees d. Letterhead e. Client files f. Lawyers g. Systems If, describe the arrangement and list all lawyers by name. Use separate sheet. AG EO 8004 LP - 11-14 Page 5 of 11
26. Have any of the Applicant s clients or former clients declared bankruptcy or become insolvent in the last year? If and these services were other than bankruptcy-related services: a. Please identify the client: b. Describe services rendered: 27. Please provide the following information about the Applicant s five (5) largest clients: Client Name Year First Represented Nature of Legal Services Provided by Applicant Percent of Gross Billings D. OPERATIONS & ADMINISTRATION 28. Does the Applicant have a full-time legal administrator? If, is the legal administrator a member of a national organization? Client Intake and Conflict Avoidance 29. Does the Applicant use a centralized computerized system to maintain client lists and check conflicts of interest? 30. If a conflict of interest is determined, do written procedures require: a. Review by a disinterested third party (such as a managing partner, managing committee or other governing body) b. Written disclosure c. Informed consent d. Written waiver of the conflict by the client 31. Under what circumstances are dual representations of clients where there is a conflict or potential conflict permitted by the firm? 32. Does the Applicant have a common process applicable to all lawyers and practice groups regarding client intake procedures? If, does this process include approval of at least one non-interested partner, the management committees or other committee before the client is accepted? 33. Is a background check performed on ever new client prior to acceptance? If, does the background check include: a. Pending/prior litigation b. Financial/credit check c. Representation history d. ne of the above e. n applicable If any of the above are not required, why not? AG EO 8004 LP - 11-14 Page 6 of 11
34. Does the Applicant require: a. Engagement letter before each new matter is accepted? b. n-engagement letters if a matter is not accepted? c. Disengagement letters when a matter ends? If any of the above are not required, why not? 35. Has the Applicant filed any suits for fees against clients or former clients of the firm in the last twenty-four (24) months? If, a. How many? b. Does the Applicant: (1) Require a minimum amount due before suit is filed? (2) Wait until the statute of limitations for malpractice has run? (3) Have the file reviewed by a disinterested party for potential malpractice claims before the suit is filed? c. Has the Applicant implemented any new policies or procedures to avoid the need for future suits for fees? If, describe: 36. How many suits for fees does the Applicant estimate filing in the next 12 months? 37. Does the Applicant refer matters outside its expertise to other law firms? If, a. Is this referral in writing? b. Does the Applicant accept referral fees or enter into fee-splitting arrangement with other firms? c. Is this disclosed to the client? Docket and Calendar Systems 38. What case management and docket control software is used by the Applicant? 39. Is this system centralized and maintained by a central docket clerk or facility? 40. Does this system automatically track statuses of limitations in the applicable jurisdiction(s)? 41. Is the data updated at least daily and backed up or stored off-site? AG EO 8004 LP - 11-14 Page 7 of 11
Training and Supervision 42. Within the last 24 months, has the Applicant known or had reason to suspect that any lawyer(s) were impaired? For the purposes of this question, impaired should include any medical, mental or substance abuse problem interfering with the individual s ability to practice law. If, please describe the circumstances, including the measures taken by the Applicant to review and supervise the lawyers work: 43. Does the Applicant require a routine review of every associates work? 44. Does the Applicant require at least an annual review of all partners work? 45. Does the Applicant have part time or independent contractor attorneys? If, a. How many? b. What is the method utilized to supervise the work of these attorneys? c. Is the Applicant s conflict of interest system updated to include potential related conflicts? d. Do these lawyers maintain separate errors & omissions insurance? 46. Does the Applicant have written policies and procedures governing the following: a. Participation on social media sites? b. Blogging, tweeting or similar activities? c. Encryption of emails and other data? d. Data security and network security and privacy? e. Use of portable electronic devices or cloud storage? If to any of the above, briefly describe the Applicants policies: 47. Does the Applicant have any policies regarding advertising and use of the firm name? Outside Interests 48. Has the Applicant or any of the Applicant s lawyers: a. Served in a position of director, officer, or partner of any client business or organization? b. Held an equity or debt interest in any business or organization that is also a client of the Applicant s firm? c. Served as an employee of any present or former client? If to any part of the above questions, complete an Outside Interests Supplement. 49. Are Applicant firm members allowed to enter into business ventures with clients? If, are conflict waivers obtained? AG EO 8004 LP - 11-14 Page 8 of 11
E. CLAIMS HISTORY 50. During the past five (5) years, has any claim that may fall within the scope of the proposed insurance been made against the Applicant or against any entity or individual proposed for coverage under this insurance? If, please provide the following information for all such claims as an attachment to this Application: dates of loss, claimant name, all defense and indemnity payments, all defense and indemnity reserves (if claims are open), and claim status (open/closed). NOTE: WITHOUT PREJUDICE TO ANY OTHER RIGHTS, DEFENSES OR REMEDIES OF THE UNDERWRITER, IT IS AGREED THAT ANY CLAIM REQUIRED TO BE DISCLOSED IN RESPONSE TO QUESTION 50 IS EXCLUDED FROM THE PROPOSED INSURANCE. 51. Is the Applicant or any entity or individual proposed for coverage under this insurance aware of any fact, circumstance, situation, transaction, event, act, error or omission that the Applicant, any such entity, or any such individual has reason to believe may, or could reasonably be foreseen to, give rise to a claim that may fall within the scope of the proposed insurance? If, provide full details on a separate sheet. NOTE: WITHOUT PREJUDICE TO ANY OTHER RIGHTS, DEFENSES OR REMEDIES OF THE UNDERWRITER, IT IS AGREED THAT ANY CLAIM ARISING FROM ANY FACT, CIRCUMSTANCE, SITUATION, TRANSACTION, EVENT, ACT, ERROR OR OMISSION REQUIRED TO BE DISCLOSED IN RESPONSE TO QUESTION 51 IS EXCLUDED FROM THE PROPOSED INSURANCE. 52. Has the Applicant or any member of Applicant s firm ever been disbarred, refused admission to practice law, suspended, reprimanded, sanctioned, fined, placed on probation, held in contempt or been the subject of any disciplinary complaint, grievance or action by any court, administrative agency or regulatory body? If, provide full details on a separate sheet. F. FRAUD WARNINGS 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 guilty of committing a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties. ALABAMA AND MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. ARKANSAS, MINNESOTA, AND OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she 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, which is a crime. COLORADO APPLICANTS: 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 policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder 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 APPLICANTS: 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 APPLICANTS: 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. KANSAS APPLICANTS: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act. KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime. AG EO 8004 LP - 11-14 Page 9 of 11
LOUISIANA, NEW MEXICO AND RHODE ISLAND APPLICANTS: 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. MAINE, TENNESSEE, VIRGINIA AND WASHINGTON APPLICANTS: 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. NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. OKLAHOMA APPLICANTS: 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 AND TEXAS APPLICANTS: Any person who makes an intentional misstatement that is material to the risk may be found guilty of insurance fraud by a court of law. PENNSYLVANIA APPLICANTS: 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. PUERTO RICO APPLICANTS: 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. G. SIGNATURE AND AUTHORIZATION The undersigned, as the authorized agent of all individuals and entities proposed for this insurance, declares that, to the best of his/ her knowledge and belief, after reasonable inquiry, the statements in this Application and any attachments or information submitted with this Application (together referred to as the Application ) are true and complete. For Florida Applicants, the preceding sentence is replaced with the following sentence: The undersigned, as authorized agent of all individuals and entities proposed for this insurance, represents that, to the best of his/her knowledge and belief, after reasonable inquiry, the statements in this Application and any attachments or information submitted with this Application (together referred to as the Application ) are true and complete. The Underwriter will maintain the information contained in and submitted with this Application on file. The information in this Application is material to the risk accepted by the Underwriter. If a policy is issued it will be in reliance upon the Application, and the Application will be the basis of the contract. The Underwriter will maintain the information contained in and submitted with this Application on file. The information in this Application is material to the risk accepted by the Underwriter. If a policy is issued it will be in reliance by the Underwriter on the Application, and the Application will be the basis of the policy. The Underwriter is authorized to make any inquiry in connection with this Application. The Underwriter s acceptance of this Application or the making of any subsequent inquiry does not bind the Applicant or the Underwriter to complete the insurance or issue a policy. The information provided in this Application is for underwriting purposes only and does not constitute notice to the Underwriter under any policy of a Claim or potential Claim. If the information in this Application materially changes prior to the effective date of the policy, the Applicant must notify the Underwriter immediately and the Underwriter may modify or withdraw any quotation or agreement to bind insurance. NEW YORK APPLICANTS: 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. Applicant Name By (Authorized Signature) Name/Title Date NOTE: THIS APPLICATION MUST BE SIGNED B Y A PARTNER, PRINCIPAL, DIRECTOR OR OFFICER OF THE APPLICANT ACTING AS AUTHORIZED AGENT OF ALL INDIVIDUALS AND ENTITIES PROPOSED FOR THIS INSURANCE. AG EO 8004 LP - 11-14 Page 10 of 11
Produced By (Insurance Agent) Insurance Agency Insurance Agency Taxpayer ID Agent License. or Surplus Lines. Address Email Address Street: City: State: Zip: Submitted By (Insurance Agency) Insurance Agency Taxpayer ID Agent License. or Surplus Lines. Address Street: City: State: Zip: NOTE: FOR NEW HAMPSHIRE APPLICANTS, PRODUCER S NAME AND SIGNATURE ARE REQUIRED. AG EO 8004 LP - 11-14 Page 11 of 11