Fillable Lawyers Professional Liability Insurance Application (Access E&S Insurance Services)

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Lawyers Professional Liability Insurance Application (Access E&S Insurance Services)

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Page 1 of 4
NOTICE: THIS IS A CLAIMS MADE POLICY. THIS POLICY COVERS ONLY CLAIMS FIRST MADE DURING THE
POLICY PERIOD SUBSEQUEST RENEWAL OR EXTENDED REPORTING PERIOD, IF APPLICABLE.
PLEASE ATTACH A SAMPLE OF YOUR LETTERHEAD TO THIS APPLICATION
Lawyers Professional Liability Insurance Application
Name: Phone:
Fax:
Address: __ __
Website:
E-mail:
City County State Zip
Applicant is: Proprietorship Partnership Corporation Association LLP LLC Other
Year Firm Established: _________________
Has the applicant merged with or acquired any firms in the last 3 years? (If yes, please provide details)
Do you have more than one office location? (If yes, please complete the Additional locations supplement)
$100,000/$300,000
$500,000/$1 million
$1 million/$2 million
$250,000/$500,000
$750,000/$750,000
$2 million/$2 million
$500,000/$500,000
$1 million/$1 million
$2 million/$4 million
NAME
STATUS
DESIGNATION
CODES *
YEAR
FIRST
ADMITTED
TO BAR
AVERAGE
HOURS
WORKED
PER WEEK
“CLE”
HOURS
IN THE
LAST
YEAR
1.
2.
3.
4.
5.
6.
* S-Sole proprietor P-Partner/Member E-Employed lawyer OC-Of Counsel IC-Independent Contractors
Total number of lawyers who left firm in past year.
Current total number of non-lawyer employees.
Attach separate sheet if necessary.
2. Limits Requested – Per Claim/Aggregate (Check all that apply)
1. Applicant Information
4. Personnel-List all Lawyers to be covered including; yourself; of counsel; IC; and per diem - working on behalf of your firm
3. Per Claim Deductible Requested $5,000 minimum –
ACCESS E&S INSURANCE SERVICES, INC
www.access-es.com
Page 2 of 4
Annual receipts: last 12 months: $___________; previous year: $_______________ next previous year: $_______________
A. Indicate the percentage of gross billable dollars by area of practice for the last fiscal year.
Admiralty/Marine
____%
Entertainment*
____%
Securities/state & Federal(SEC)*
____%
Administrative
____%
Environmental
____%
Securities – Private Placement*
____%
Anti-Trust Trade Regulation
____%
ERISA
____%
Securities – Bonds*
____%
Arbitration/Mediation
____%
Est. Plan/Probate/Trusts/Wills
____%
Social Security Disability
____%
Banking*
____%
Government/Municipalities
____%
Tax Preparation
____%
Bankruptcy &/or Collection
____%
Immigration
____%
Tax Opinions
____%
Bodily Injury/Defense
____%
International Law
____%
Workers Comp/Defense
____%
Bodily Injury/Plaintiffs*
____%
Investment Counseling
____%
Workers Comp./Plaintiff*
____%
Copyright/Patent/TM*
____%
Labor Relations
____%
OTHER (Describe if over 5%)
____%
Corporate
____%
Real Estate – Residential
____%
____%
Criminal
____%
Real Estate – Commercial
____%
____%
Domestic Relations – Divorce
____%
Real Estate – Synd. Devel.
TOTAL (Must equal 100%)
%
Family Law – Not divorce
____%
Real Estate – Title Work
*Please complete appropriate area of practice supplement.
B. Does the Applicant have any high-profile clients who are entertainers,
Sports figures or public officials? Yes No
If “Yes”, please explain by attachment.
C. Does the Applicant have discretionary investment authority for any clients? Yes No
If “Yes”, please list total number of clients.
Number of Clients: _____________
Is any one client account for more than $500,000? Yes No
Is the authority limited and in writing? Yes No
D. In the last five (5) years, has any attorney with the Applicant firm, represented any
financial institution? Financial institution means any savings and loan association, bank,
credit union, savings bank, banking and loan association, commercial banking institution
lending institution, mortgage bank, or any subsidiary or lending affiliate thereof.
Yes No
If “Yes”, complete the Financial Institutions Supplemental Application.
E. Does any firm attorney serve as a director, officer, trustee
(other than estate trusts), partner or employee of any client? Yes No
If “Yes”, please complete the Outside Interests Supplemental Application.
F. Does any firm member exercise fiduciary control or possess any ownership
interest in any client or any business venture with a client? Yes No
If “Yes”, please complete the Outside Interests Supplemental Application.
5. Area of Practice
____%
0
Page 3 of 4
A.
1- Use engagement letters on all new matters? Yes No
2- Require clients to sign engagement letters/agreements? Yes No
3 -Use nonengagement and disengagement letters? Yes No
4- Use any of the following conflict avoidance methods:
Oral/Memory? Yes No
Computer? Yes No
Conflict Committee? Yes No
Index File? Yes No
5- Update its conflict avoidance system at least weekly? Yes No
6- Cross-check conflicts created by new attorneys to the firm? Yes No
7- Insist on obtaining a written waiver from its clients in order to perform
on-going services when an actual/potential conflict exists? Yes No
8- Allow attorneys to enter into business with firm clients? Yes No
9- Require disclosure if such relationships are permitted? Yes No
10- Maintain a calendar system using these methods:
Single Calendar Yes No
Dual Calendar Yes No
Tickler Cards Yes No
Computer Yes No
Master Listing Yes No
11- Use two individuals to maintain its calendar system? Yes No
12- Update its calendar system at least weekly? Yes No
13- Place ultimate responsibility for calendar system with a firm lawyer? Yes No
B. If you are a sole practitioner, have you designated a lawyer(s) who will be responsible
for your affairs if you are absent for an extended period of time (i.e., vacation, etc.) Yes No
C. How many times has the Applicant sued a client for unpaid fees in the last 2 years? _________
D. Does any single client account for more than twenty-five percent (25%) of the Applicant’s gross annual billings?
Yes No
If “Yes”, please identify client, nature of client’s business, and the percentage of billings, by attachment.
After inquiry, has any lawyer to be insured under this policy:
A. ever had professional liability insurance cancelled or nonrenewed? Yes No
If “Yes”, please explain by attachment.
B. ever been disbarred or been the subject of reprimand, censure, sanction or other
disciplinary action, or been refused admission to the Bar? Yes No
If “Yes”, please explain by attachment.
C. been the subject of a professional liability claim or suit in the last five (5) years? Yes No
D. knowledge of any circumstance, act, error, or omission that could result in a professional
liability claim? Yes No
If “Yes”, to C. or D. above, please complete a Claims Supplemental Application for each instance.
6. Firm Policies and Procedures
7. Claims, Incidents & Disciplinary Actions
Page 4 of 4
Current Prior Acts Exclusion date and/or retroactive date .
Current Individual Attorney Prior Acts date? (Y or N) ________ Please attach a schedule with the name and dates
Please list professional liability insurance carried by the Applicant and predecessor firms over the last three (3) years:
Inception
From (Mo-Day-Yr)
Expiration
To (Mo-Day-Yr)
Insurance
Company
Policy Number
Limits of Liability
Deductible
(if any)
Is the applicant being covered by an Extended Reporting Period Endorsement? Yes No
If “Yes”, please attach details.
Please Read carefully and Sign Below where indicated.
The undersigned proprietor, partner, member or officer, acting on behalf of the applicant and all others to be insured,
hereby,
(A) declares after diligent inquiry that the above statements and particulars are true and that no material facts have been
suppressed or misstated:
(B) acknowledges that it is understood and agreed that (1) the completion of this application does not bind Amtrust
International Insurance Underwriters, LTD. to issue nor the Applicant to purchase the insurance; (2) however, this
application will be the basis of the contract if a policy is issued; and (3) all written statements and material furnished
to the Company in conjunction with this application are hereby incorporated by reference into this application and
made part hereof; and
(C) acknowledges that, in the event the Company issues a policy, (1) the Company in providing coverage will have relied
upon, as representations, the declarations and statements which are contained in or attached to or incorporated into
the policy; and (2) in the event of a claim for which coverage would otherwise be available under this policy, the
Applicant will be required to be defended by lawyers appointed by the Company and if the Insured elects to handle
any claim without such lawyers or otherwise without the Company’s involvement, then no coverage for such claim will
be afforded the Applicant under the policy.
NOTICE : 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 violation.
Sign & Date in ink.
Signed by: Title:
Print Name: Date:
8. Prior Insurance
9. Signature
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Lawyers Professional Liability Insurance Application (Access E&S Insurance Services)

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Completed 8 January 2021

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