Fillable Employed Lawyers Protection Plus (Philadelphia Insurance Companies)

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Employed Lawyers Protection Plus (Philadelphia Insurance Companies)

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PI-EW-APP NY (05/10)
Page 1 of 4
___________________________________________________________________________
Name of Insurance Company to which Application is made (herein called the “Insurer”)
Employed Lawyers Protection Plus
EMPLOYED LAWYERS PROFESSIONAL LIABILITY APPLICATION – NEW YORK
NOTICE: THIS IS A CLAIMS MADE POLICY. THE POLICY PROVIDES THAT THE LIMITS OF
LIABILITY AVAILABLE TO PAY JUDGMENTS OR SETTLEMENTS SHALL BE REDUCED BY
DEFENSE COSTS. F
URTHER NOTE THAT AMOUNTS INCURRED FOR DEFENSE COSTS SHALL
BE APPLIED AGAINST THE RETENTION AMOUNT.
THIS APPLICATION DOES NOT BIND THE APPLICANT TO BUY OR THE INSURER TO ISSUE THE
INSUR
ANCE, BUT IT IS AGREE
D THAT THIS FORM SHALL BE THE BASIS OF THE CONTRACT
SHOULD A POLICY BE ISSUED, AND IT WILL BE ATTACHED TO AND BECOME PART OF THE
POLICY.
IF A POLICY IS ISSUED, IT WILL BE ON A CLAIMS-MADE BASIS.
1. Name of the Applicant:
2. Address of the main office of the Applicant:
Note: Applicant shall in
clude any and all of Applicant’s Subsidiaries
. All bolded terms have the same
meaning as the same terms in the Employed Lawyers Protection Plus policy.
3. Date of formation or incorporation:
4. State of formation or incorporation:
5. Primary Nature of Business (
include SIC
class):
6. Applican
t is a Public
Private Not For Profit entity
Also, please give the average time of service of you
r directors:
years.
If Public, please provide the exchange where you are listed and symbol:
7. Number of full-time In-Hou
se Counsel employed by the Applicant:
8.
Number of part-time In-Ho
use Counsel employed by the Applicant:
9.
Number of Independent Contractor Cou
nsel contracted by the Applicant:
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PI-EW-APP NY (05/10)
Page 2 of 4
10. Limit of Liability requeste
d: $
11. Retention requested (each claim for indemnifiable loss): $
12. Securities
Claims Sublimit of Liability reque
sted: $
(Maximum $5
,000,000)
If a Securities Claims Sublimit of Liability is requested, then these questions must be answered:
S1. Does any In-House Counsel issue legal opinions with respect to registration statements file
d with any
securities commission? Yes No
S2. Does any In-House Counsel sign registration statements of the Applicant? Yes
No
S3. Does any In-Hous
e Counsel serve on the Board of Directors or e
quivalent governing body of the
Applicant? Yes No
S4. Has the Applicant made a public offering of debt or equity within the past two (2) years?
Yes No
S5. If Applicant i
s a private company, does it have a filing requirement with the U.S. Securities an
d Exchange
Commission? Yes No
13. Does Ap
plicant plan to merge, acquire, or be ac
quired by or with another entity or consolidate any of its
Subsidiaries within the next twelve (12) months? Yes No
14. Does Applicant anticipate any registration of securities un
der the Securities Act of 1933 (or any similar
state or foreign rule or law) or any other offering of securities within the next twelve (12) months?
Yes No
15. Does any In-House Counsel issue written legal opinions to outside parties in conne
ction with sales,
acquisitions or other transactions? Yes No
16. Does any In-House Counsel serve on a due diligence committee
or perform legal professional services
in connection with any of Applicant’s mergers, acquisitions or a consolidations? Yes No
17. Does
any In-Hous
e Counsel appear in court for the Applicant or other parties in the cou
rse of his
employment for the Applicant? Yes No
18. Does any In-House Counsel provide personal legal professional
services with respect to criminal,
matrimonial or intellectual property law or estate/financial planning? Yes No
If “yes,” how often?
19. Financial information (Financial statement required if Limits of more than $1 Million are requested):
Total Assets: $
Total Liabilities: $
Current Assets: $
Current Liabilities: $
Revenues: $
Based on Financial Statement Dated: / (Month/Year)
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PI-EW-APP NY (05/10)
Page 3 of 4
20. Does the Applicant carry Directors and Officers, Employment Practices Liability, Professional Liability
Ins
urance? Yes No If “Yes,” provide the following information with regard to all insurance:
D&O EPLI E&O
Insurance Carrier
Limits of Liability $ $ $
Deductible/Retention $ $ $
Premium $ $ $
Policy Period
Retroactive Date/Continuity Date
Years of continuous coverage
21. Has any insurance carrier refuse
d, canceled o
r non-renewed the Applicant’s Directors and Officers or
other management liability insurance, Employment Practices Liability Insurance or Professional Liability
Insurance for In-House Counsel? (MISSOURI APPLICANTS NEED NOT REPLY.) Yes No
If “Yes,” please provide the date, carrier, coverage and reason for each declination, cancellation or
non-rene
wal.
22. Has any In-House Counsel bee
n subje
ct to any discipline by, or been refused admission to any bar, court
or administrative agency? Yes No If “Yes,” attach complete information.
23. Has the Applicant or
any In-House Counsel been charged with a violation of any federal, state or foreign
securities law, rule or regulation in any court or by any civil, criminal, administrative or regulatory agency?
Yes No If “Y
es,” attach complete information.
24. After reasonable inquiry, is any In-Ho
u
se Counsel or the Applicant aware of any claims or actions
against any person proposed for insurance in his or her capacity as In-House Counsel within the past
three (3) years? Yes No If “Yes,” attach complete information.
25. After reasonable inquiry, is any In-Hous
e Counsel or the Applicant, aware of any act, error or omission
which may reasonably be expected to give rise to a claim against any In-House Counsel? Yes No
If “Yes,” attach complete information.
It is agreed that with respect to Questions 22, 23, 24 and 25
above, that if any answer is in the affirmative, then
such Claim, proceeding or action and any Claim or action arising from such Claim, proceeding, action, knowledge,
information or involvement is excluded from the proposed coverage. It is further agreed that all written statements
and materials furnished to the insurer in conjunction with this Application along with all public documents
(including 10-Qs, 10-Ks and other filings) are hereby incorporated by reference into this application and made a
part hereof.
NOTICE TO NEW YORK APPLICANTS: ANY PERSON WHO KNO
WINGLY 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.
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PI-EW-APP NY (05/10)
Page 4 of 4
Signature
Na
me: Title:
(Please Print) (President, Chairman or General Counsel)
Date: Signature: ____________________________________
The above signed represents that he/she is auth
orized an
d has the power to complete and execute this Application,
including the Representation Statement on behalf of the Applicant and their respective Directors, Officers or other
insured persons and declares that the statements set forth in this Application are true. The above signed further
agrees that if the information supplied on this Application changes between the date of this application and the
effective date of the insurance, the Applicant will immediately notify the insurer of such changes, and the insurer
may withdraw or modify any outstanding quotations and/or authorization or agreement to bind the insurance.
ADDITIONAL INFORMATION
This page may be used to provide additional information to any question on this application. Please
identif
y the quest
ion number to which you are referring.
__________________________________________
Signature Date
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Employed Lawyers Protection Plus (Philadelphia Insurance Companies)

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Completed 7 November 2020

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