Application for Lawyers Professional Liability Insurance

1.	Instructions:
	A.	All questions must be answered completely.  Please type or print clearly. If any questions are   considered "Not Applicable",  please explain why.
	B.	If you need more space,  please continue on a separate sheet and indicate question number.
	C.	Please complete application form and supplements where required.
	D.	This application and all supplement forms must be signed and dated by a principal of the firm.
	E.	Enclose a sample of current letterhead with the application.
2.	A.	Name of Applicant:
				Individual   Partnership   Professional Corp.   Other
	B.	Address:
		City:
		County:		United States Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia Botswana Brazil Brunei Bulgaria Burkina Faso Burma Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central Afr. Rep. Chad Chile China Colombia Comoros Congo Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dom. Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia Georgia Germany Ghana Gibraltar Greece Grenada Guadeloupe Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Ivory Coast Jamaica Japan Jersey Jordan Kazakhstan Kenya Kuwait Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Mauritania Mauritius Mexico Moldova Monaco Mongolia Morocco Mozambique Namibia Nepal Netherlands Netherlands Antilles New Zealand Nicaragua Niger Nigeria North Korea Norway Oman Pakistan Panama Paraguay Peru Philippines Poland Portugal Qatar Romania Russia Rwanda San Marino Saudi Arabia Senegal Sierra Leone Singapore Slovakia Slovenia Somalia South Africa South Korea Spain Sri Lanka Sudan Suriname Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Tobago Togo Trinidad Tunisia Turkey Turkmenistan Turks and Caicos Islands Uganda Ukraine U.A.E. United Kingdom United States Uruguay Uzbekistan Venezuela Vietnam Yemen Yugoslavia Zambia Zimbabwe
		State:		Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
		Zip:
		Federal Tax I.D. Number:
	C.	Telephone:
		Fax:
	D.	Branch Office Address(es): On a separate addendum,  please also list all lawyers and staff members (including a description of the duties of each staff member) at each location:
	E.	Date Commenced Business:
	F.	Total Number of Lawyers:
		Currently:
		End of Last Calendar Year:
	G.	Total Number of:
		Principals:
		Employed Lawyers:
		Of Counsel :
		Paralegals:
		Other Staff :
	Please complete Supplement 1.
	H.	List all predecessor firms of Applicant: (A "predecessor firm" is one that has undergone a dissolution, if at least two-thirds of the lawyers in that firm as of the dissolution are now with the Applicant firm.)
		Name Dates of Existence  Total number of lawyers At Dissolution  Total number of lawyers who joined Applicant firm or predecessor firm  1.  2.  3.
	I.	Internet Presence:
		Applicant's web site, if any:
		E-mail address of Applicant's primary contact person:
3.	A.	Total Gross Billings/Income (whether collected or not, including, without limitation, an estimate of all fees, contingent or otherwise, or any other income derived) for:
		Last Fiscal Year :		$ for 12 months ending :
		Current Fiscal Year:		$
	B.	Indicate Percentage of "Total Gross Income" derived from: (OVERALL TOTAL MUST EQUAL 100%)
Area of Practice  Current Fiscal  Year %   Last Fiscal   Year %  Additional Requirements Banking  Please complete Supplement 2 BI/PD Plaintiff  Please complete Supplement 8 Worker's Compensation Plaintiff   Corporate Formation/Alteration   Mergers/Acquisition  Describe on a separate addendum. Entertainment*   Investment Advice/ Financial Consulting*   Oil & Gas   Real Estate*  Please complete Supplement 4 Securities Practice* including Syndications/Tax Shelters/Ltd. Partnerships  Please complete Supplement 3 Taxation   Sub Total:   Environmental  Please complete Supplement 10. Patent*   Copyright/Trademark  Please complete Supplement 11. Estate/Probate Trust   General Corporate  Describe on a separate addendum. Municipal Law  Describe on a separate addendum Sub Total:   Admiralty   BI/PD Defense   Civil Litigation   Divorce   Adoption or Surrogacy  Please describe on a separate addendum. Other Family Law  Describe on a separate addendum. Labor Law   Bankruptcy   Unlawful Detainer   Worker's Compensation Defense   Criminal  Describe on a separate addendum. Sub Total:   Other ( Please Describe)               Sub Total:       GRAND TOTAL:       %     %   MUST EQUAL 100%
	*Note: If a policy is issued, Securities, Entertainment, Patent, and certain other activities mentioned in this Application will not be afforded coverage.
	C.	On a gross billing basis for the current fiscal year, indicate the percentage of revenue derived from representing
		1)  Plaintiffs:		%
		2)  Defendants:		%
		3)  Others (including Petitioners respondents)		%
		Items 1), 2), and 3) must total 100%.
	D.	Does the Applicant or any of its lawyers currently, or did the Applicant or any of its lawyers at any time in the last ten (10) years prior to the signing of the Application, provide legal services to any Financial Institution?   Yes   No If yes,  please complete Supplement 2.
	E.	Does the Applicant or any of its lawyers currently, or did the Applicant or any of its lawyers at any time in the last five (5) years, provide any other professional services apart from legal work? Yes   No If yes,  please give details on a separate addendum.  Please include details of applicable insurance.
	F.	Does the Applicant currently have, or has the Applicant at any time in the last five (5) years had, any one client or group of related accounts, which produce more than 10% of Total Gross Billings? Yes   No If yes,  please attach a separate addendum explaining in detail the name and business activities of the client, the service(s) you provide or provided, areas of law involved and your relationship other than as independent legal advisor
CONTROLS
4.	MANAGEMENT
	A.	Is the Applicant managed by a management committee? Yes   No
	B.	How many partners or officers comprise the management committee?   N/A
	C.	Does the Applicant employ an administrator? Yes   No
	D.	What percentage of the administrator's time is devoted to the practice of law?  %  N/A
	E.	Does the Applicant use a peer review system to evaluate the performance of partners or officers? Yes   No
5.	NEW BUSINESS
	A.	Are new clients subject to approval of the Applicant's management committee or at least two (2) partners or officers of the Applicant? Yes   No N/A
	B.	Is information as to all new clients made available on at least a weekly basis to all partners or officers of the Applicant? Yes   No N/A
	C.	Does the Applicant maintain a system to avoid conflicts of interest? Yes   No
	D.	Is the conflicts system computerized? Yes   No
	E.	Is a lawyer who generates new business required to work under supervision of a partner or officer having specific expertise in the matter? Yes   No N/A
6.	OUTSIDE COMMUNICATIONS
	A.	Is it the Applicant's standard practice to use engagement and disengagement letters when agreeing or declining to represent a client? Yes   No
	B.	Is it the Applicant's standard practice to outline in writing the Applicant's billing policy and procedure when agreeing to represent a client? Yes   No
	C.	Do major opinion letters have to be approved by at least two partners or officers of the Applicant? Yes   No N/A
	D.	Do letters to auditors have to be approved by at least two partners or officers of the Applicant? Yes   No N/A
		If the answer to any of these questions is no,  please give written explanation.
7.	DOCKET AND CALENDAR
	A.	Does the Applicant maintain a docket control system and procedure with at least two (2) independent date controls? Yes   No
	B.	Is the docket control system and procedure computerized? Yes   No
	C.	Does the docket control system and procedure produce a weekly calendar? Yes   No
	D.	Does the docket control system and procedure cover all aspects of the Applicant's practice? Yes   No
	E.	Does the docket control system and procedures require lawyers to both calendar and remove from the calendar all filing dates? Yes   No
	F.	Are open calendar entries on the planned docket control system and procedure circulated to all lawyers or, if the Applicant is divided into formal departments, to all lawyers in the appropriate department? Yes   No N/A
8.	TRAINING AND SUPERVISION
	A.	Does the Applicant maintain a formal training program for new lawyers as to office and court procedures? Yes   No N/A
	B.	Are all lawyers (including any Of Counsel) of the Applicant firm in compliance with the continuing education requirements established by the State Bar of California? Yes   No If no,  please explain the reasons for noncompliance on a separate addendum.
	C.	Are all associates of the Applicant under the direct supervision of a partner or officer? Yes   No N/A
	D.	Are all associates of the Applicant subject to periodic, written review? Yes   No N/A
9.	MISCELLANEOUS
	A.	Does the Applicant firm have a policy forbidding any of its lawyers (including any Of Counsel) from participating as a shareholder, partner, officer or director in any client or in any of the client's related entities? Yes   No If no,  please give details on a separate addendum.
	B.	Is any lawyer (including Of Counsel) of the Applicant firm currently participating or has participated in the past as an officer, partner, director, or shareholder in any entity other than the Applicant? Yes   No If yes, give details on a separate addendum..
	C.	How many suits and fee arbitrations for collection of fees and/or recovery of costs have been commenced by the Applicant during the past five (5) years?
	D.	How many suits, counterclaims, and fee arbitrations have been commenced against the Applicant, contesting any fees and/or costs charged by Applicant during the past five (5) years?
	E.	What percentage of the Applicant's billings are more than 90 days overdue?  %
	F.	Does/Has any current or past lawyers, Of Counsels or employees of the Applicant:
		(i)  Had his/her legal license or authority to practice law revoked? Yes   No
		(ii)  Have knowledge of any complaint and/or disciplinary action regarding Applicant (including any lawyer or staff member) reported to the state or local bar or ABA? Yes   No
		(iii) Been subject to any investigation, fine, sanction, reprimand, or criminal penalty related to performance of professional services? Yes   No
		If yes to any of the above, give the details on a separate addendum, including the date and outcome.
	G.	Has Applicant or any of its past or present lawyers moved to withdraw, or been disengaged at the request of a client during the past two (2) years? Yes   No If yes, give details on a separate addendum.
10.	A.	Has the Applicant or any of its attorneys (including any Of Counsel) ever had an application or policy for professional liability insurance declined, cancelled or non-renewed? Yes   No If yes,  Please provide details (including date, carrier and reason(s) for action) on a separate addendum.
	B.	After inquiry, have any claims or suits been made against any lawyer (including any Of Counsel) of the Applicant firm or any past / present owners, partners, shareholders, corporate officers or employees or its predecessors in business during the last five (5) years? Yes   No If yes, how many claims or suits  Please complete enclosed Supplement 5 for each claim or suit.
	C.	After inquiry, have any claims or suits been made by any lawyer (including any Of Counsel) of the Applicant firm or any of its past or present owners, partners, shareholders, corporate officers or employees or its predecessors in business during the last five (5) years (i.e., claims or suits made as a plaintiff and not as an attorney representing a client)? Yes   No If yes, how many claims or suits  Please complete enclosed Supplement 5 for each claim or suit. ss
	D.	After inquiry and based upon a reasonable belief, is/are any lawyer (including any Of Counsel) of the Applicant firm aware of any circumstances, allegations, or contentions as to any incident which may result in a claim being made against the Applicant or any of its past or present owners, partners, shareholders, corporate officers, of counsels or employees or its predecessors in business during the last five (5) years? Yes   No If yes, how many incidents  Please complete enclosed Supplement 5 for each incident.
11.	Please give details of previous Insurance (last five (5) years) including periods of coverage (including predecessor Applicants) and any extended claims reporting period ("tail") coverage. INFORMATION BELOW MUST INCLUDE POLICY NUMBER
Carrier Policy Number Limits Each Claim/Aggregate Deductible # of Attorneys Paid Premiums ($) Coverages Dates Effective From To 1. 2. 3. 4. 5.
		Retroactive Date of current coverage:
		Please provide a copy of the Declarations Page of (or Endorsement to) Applicant's current policy showing the retroactive date listed above.
12.	Please state coverage Limits and Deductibles Requested
	A.	Coverage Limits of Liability
		$ Any one Claim and in the Aggregate, including Costs and Expenses
	B.	Deductible
		$ Each and every Claim including Costs and Expenses
	REPRESENTATION BY APPLICANT I/We represent that the information contained herein is true as of the date that the application is executed and that it shall be the basis of the policy of insurance and deemed incorporated therein, if the Company accepts this application by issuance of a policy. It is hereby agreed and understood that this representation constitutes a continuing obligation to report to the Company as soon as practicable any material change in the circumstances of the Applicant's practice of law, including but not limited to: size of firm, area of practice engaged in by the firm and information contained on each supplemental application submitted by the Applicant. In applying for coverage, the Applicant agrees that in the event of covered losses he will be required to be defended by the Company lawyers. If the Applicant elects to handle a claim without in any way involving the Company, then no coverage for such claim is afforded the Applicant under the policy. Signing this application does not bind the Applicant or the Company to complete the insurance, but it is agreed that the statements and particulars contained herein will be relied upon by the Company should a policy be issued. This application is signed on behalf of all owners, partners, shareholders, corporate officers and employees
	Authorized Signature of Applicant:
	Title:
	Date:
	APPLICANT'S WARRANTY OF NO KNOWN AND UNREPORTED CLAIMS OR INCIDENTS I, the undersigned, warrant on behalf of the Applicant that Applicant has no knowledge of any claims, legal or otherwise, which have been or may be made, against any entity or individual for which insurance is requested, which has not been reported previously to you or another insurance company. In addition, after making reasonable inquiries, Applicant is not aware of any act, error or omission, or allegations of any act, error or omission, or any other circumstances or incidents which could give rise to a claim as a result of the law firm's operations or any individual's activities on behalf of the law firm. Applicant understands that the insurance company's willingness to provide coverage or reinstate coverage is based on this Warranty, which shall be deemed material. Applicant also understands that all such unreported claims or incidents which later result in a claim will not be covered by the company's policy, if issued
	Authorized Signature of Applicant:
	Title:
	Date:
	PLEASE MAKE CERTAIN ALL QUESTIONS ARE ANSWERED AND THAT ALL APPLICABLE SUPPLEMENTAL FORMS ARE COMPLETED
	THIS APPLICATION WILL NOT BE PROCESSED UNLESS ALL QUESTIONS ON THIS APPLICATION AND APPLICABLE SUPPLEMENTS ARE ANSWERED.