PROFESSIONAL LIABILITY (OTHER THAN MEDICAL) LW AP 04 03 11
KENTUCKY – APPLICATION FOR LAWYERS
PROFESSIONAL LIABILITY INSURANCE
THIS APPLICATION IS FOR A CLAIMS-MADE AND REPORTED POLICY. CLAIMS MUST BE FIRST MADE AGAINST THE INSURED DURING THE POLICY PERIOD OR EXTENDED REPORTING PERIOD, IF APPLICABLE, AND REPORTED TO US AS SOON AS PRACTICABLE, BUT IN NO EVENT LATER THAN THIRTY (30) DAYS AFTER THE END OF THE POLICY PERIOD, OR AFTER THE END OF THE EXTENDED REPORTING PERIOD, IF APPLICABLE. THE INSURANCE FOR WHICH THIS APPLICATION IS MADE APPLIES ONLY IF THE WRONGFUL ACT OUT OF WHICH THE CLAIM AROSE OCCURRED ON OR AFTER THE RETROACTIVE DATE, IF ANY, SHOWN IN THE DECLARATIONS AND BEFORE THE END OF THE POLICY PERIOD. DAMAGES AND DEFENSE EXPENSES ARE PAYABLE WITHIN THE LIMITS OF INSURANCE. IF ISSUED, PLEASE READ YOUR POLICY CAREFULLY.
SECTION I – GENERAL INFORMATION Name Of Applicant Or Firm:
Mailing Address Of Principal Office:
Phone Number: Fax Number:
Firm's Web Site: Firm's Email Address: Branch Office? If Yes, please provide Mailing Address(es):
Yes No
Branch Office Mailing Address:
Phone Number: Fax Number:
Branch Office Mailing Address:
Phone Number: Fax Number:
Date Firm Was Established: Type Of Firm:
Sole Practitioner Limited Liability Partnership
Partnership Limited Liability Company
Professional Association or Corporation Other (describe): Provide Name Of Predecessor Firms And Dates Of Existence:
Has your firm's lawyers professional liability insurance ever been canceled
or nonrenewed for reasons other than nonpayment of premium? Yes No If Yes, please explain:
SECTION II – COVERAGE REQUESTED Limit Of Insurance: Each Claim $
Limit Of Insurance: Aggregate $ Deductible: $
Proposed Effective Date: Proposed Retroactive Date: SECTION III – ATTORNEY INFORMATION
Attorney Name P A O I
Part- time*
Full- time
State(s) Licensed
In/Year
Total No. Years In Practice
P = Partner A = Associate O = Of Counsel I = Independent Contractor * Part-time = An attorney working less than 1,000 hours during the annual policy period
Has the license(s) of any attorney listed above ever been suspended or
revoked? Yes No
If Yes, please explain:
Number Of Paralegals Number Of Clerks Number Of Other Employees
AREAS OF PRACTICE
Area Of Practice % Area Of Practice %
Admiralty/Maritime – Defense Intellectual Property – Patent Admiralty/Maritime – Plaintiff Intellectual Property – Trademark
Antitrust/Trade Regulation Investment Counseling/Money Management Arbitration/Mediation Labor/Employment – Employee
Aviation Labor/Employment – Management
Banking/Financial Institutions Labor/Employment – Union
Bankruptcy Litigation – Defense
Bodily Injury/Personal Injury – Defense Litigation – Plaintiff
Bodily Injury/Personal Injury – Plaintiff Medical Malpractice – Defense Civil Rights/Discrimination Medical Malpractice – Plaintiff Class Action – Defense Mergers/Acquisitions
Class Action – Plaintiff Municipal/Government – Zoning And Planning
Collection/Repossession/Foreclosures Municipal/Government – Other (Not Bonds)
Communications/FCC Oil/Gas/Minerals
Construction (Building Contracts) Public Utilities Consumer Claims (Not Class Action) Real Estate – Commercial Corporate (Other Than Mergers And
Acquisitions)
Real Estate – Escrow Agent
Criminal Real Estate – Residential
Divorce Real Estate – Syndication/Development Employee Benefits/ERISA/Pension Real Estate – Title Work
Entertainment/Sports Securities/Bonds/Secured Transactions
Environmental Social Security/Elder
Family (Other Than Divorce) Tax – Business Foreign/International Tax – Individual
Healthcare Tax – Opinion
Immigration Wills/Estates/Trusts/Probate
Insurance Workers' Compensation – Defense Intellectual Property – Copyright Workers' Compensation – Plaintiff
Other (Describe):
TOTAL MUST EQUAL 100%
Lawyers Who Currently Hold Position Or Capacity In Other Than The Named Insured Firm Name Of Lawyer Name Of Business Nature Of Business Position
% Of Ownership Interest
SECTION IV – SYSTEMS AND PROCEDURES Does your firm have procedures in place that include the regular use of a centralized conflict of interest avoidance system when accepting new clients
or a new matter from existing clients? Yes No
Does or has any current or former attorney of your firm served as an officer, director, partner, employee, principal shareholder or member or in any other
management capacity for a client? If Yes, please explain: Yes No
Does any attorney in the firm have an equity interest in any one client? If Yes, please explain:
Yes No
Does the firm use a peer review system to evaluate the performance of
partners or officers? Yes No
Does the firm maintain a planned docket control system and procedure with
at least two independent date controls? Yes No
Is the docket control system and procedure computerized? Yes No
Does the planned docket control system and procedure produce a weekly
calendar? Yes No
Does the planned docket control system and procedure cover all aspects of
the firm's practice? Yes No
Does the planned docket control system and procedure require lawyers to
both calendar and remove from calendar all filing dates? Yes No
Are open calendar entries on the planned docket control system and procedure circulated to all lawyers or, if the firm is divided into formal departments, to all lawyers in the appropriate department?
Yes No
Is the firm managed by a management committee? If Yes, answer the following:
Yes No
How many partners or officers comprise the management committee?
Does the firm employ an administrator? Yes No
What percentage of the administrator's time is devoted to the practice of
law? %
Does the firm sue clients for fees? Yes No
If so, how many times in the past three years?
Does the firm issue engagement or disengagement letters to clients? Yes No
SECTION V – FIRM'S INSURANCE COVERAGE HISTORY Prior Insurance Information:
(List prior lawyers professional liability insurance for the past three years, both stand-alone policies and supplemental coverage provided under some other type of insurance.)
Period Period Period
Insurer Insurer Insurer
Limit Of Insurance Limit Of Insurance Limit Of Insurance
$ $ $
Deductible Deductible Deductible
$ $ $
Premium Premium Premium
$ $ $
Number Of Lawyers Number Of Lawyers Number Of Lawyers
Coverage is requested to be effective on:
Provide the date of the Applicant Firm's first claims-made policy (maintained without interruption to date):
Does your firm's current policy contain a prior acts limitation or retroactive date
applicable to your firm or any individual attorney? Yes No
If Yes, please provide date: Attach a copy of the endorsement.
Has your firm ever purchased an Extended Reporting Period option? Yes No If Yes, provide the full details:
SECTION VI – CLAIM/INCIDENT/DISCIPLINARY INFORMATION
Has anyone in the firm ever been convicted of or pled guilty to a crime? Yes No
Is there currently any pending litigation or claims against the named applicant, firm and/or any of the insured attorneys? This includes disciplinary actions, malpractice claims, any act, error or omission, or other circumstance which could be expected to
give rise to a claim. Yes No
Are any of the insured attorneys aware of any matters that could potentially give rise to a claim? If so, approximately when did those insured attorneys become aware of
any such matters? Yes No
Include the nature of the allegations or potential claim, the disposition (damages/settlements) and/or final payment, if any, in the space provided below. If more space is necessary, use Form LW AP 01:
Name Of The Insured Attorney(s) Involved:
Name Of Claimant/Litigation Or Potential Claim/Litigation Involved:
Dates Of Litigation Involved (If Applicable):
Status Of Litigation (If Applicable):
Summary Of Allegations/Amount Of Damages At Issue (If Applicable):
Applicant's fiscal year ends on: Month: Day:
Indicate the gross income for the applicable fiscal year (gross income means all sums billed to clients for services rendered):
(a) Actual gross income for second previous fiscal year: $ (b) Actual gross income for immediate past fiscal year: $ (c) Estimated gross income for current fiscal year: $
FRAUD STATEMENT
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.
NOTICE TO APPLICANT – PLEASE READ CAREFULLY
FOR THE PURPOSE OF THIS APPLICATION, THE UNDERSIGNED REPRESENTS THAT TO THE BEST OF HIS/HER KNOWLEDGE THE STATEMENTS HEREIN ARE TRUE AND COMPLETE. THE INSURER IS AUTHORIZED TO MAKE ANY INQUIRY IN CONNECTION WITH THIS APPLICATION. SIGNING THIS APPLICATION DOES NOT BIND THE INSURER TO ISSUE, OR THE APPLICANT TO PURCHASE, ANY INSURANCE POLICY.
THE INFORMATION CONTAINED IN AND SUBMITTED WITH THIS APPLICATION IS ON FILE WITH THE INSURER. THIS APPLICATION WILL BECOME A PART OF SUCH POLICY, IF ISSUED. THE INSURER WILL HAVE RELIED UPON THIS APPLICATION AND ATTACHMENTS IN ISSUING THIS POLICY. IN THE EVENT THAT THE APPLICATION CONTAINS ANY MISREPRESENTATION OR MISSTATEMENT OF A MATERIAL FACT, THIS POLICY SHALL NOT AFFORD COVERAGE TO ANY INSURED WHO KNEW OF SUCH MISREPRESENTATION OR MISSTATEMENT.
IF THE INFORMATION IN THIS APPLICATION MATERIALLY CHANGES PRIOR TO THE EFFECTIVE DATE OF THE POLICY, THE APPLICANT MUST PROVIDE WRITTEN NOTIFICATION TO THE INSURER, WHO MAY MODIFY OR WITHDRAW THE QUOTATION.
THE UNDERSIGNED FURTHER AGREES TO AUTHORIZE THE RELEASE OF ANY AND ALL INFORMATION IN THIS APPLICATION TO A LOSS CONTROL PROVIDER THAT PROVIDES LOSS CONTROL SERVICES TO THE INSURER AND TO COMPLY WITH THE TERMS AND CONDITIONS OF THOSE LOSS CONTROL SERVICES.
THE UNDERSIGNED DECLARES THAT THE INDIVIDUALS AND ORGANIZATIONS PROPOSED FOR THIS INSURANCE HAVE BEEN NOTIFIED THAT:
A. THIS POLICY APPLIES ONLY TO CLAIMS FIRST MADE OR DEEMED MADE AGAINST THE INSURED DURING THE POLICY PERIOD OR ANY EXTENDED REPORTING PERIOD, IF APPLICABLE; AND
B. THE LIMIT OF LIABILITY IS REDUCED BY AMOUNTS INCURRED AS DAMAGES AND SUCH EXPENSES WILL BE SUBJECT TO THE DEDUCTIBLE AMOUNT.
NOTE:
This application must be signed by the officer or partner of the first Named Insured firm acting as the authorized officer or partner of the applicant applying for this insurance.
Printed Name Of Officer Or Partner Of The Firm:
Signature Of Officer Or Partner Of The Firm:
Title: Date:
