Commercial Insurance Underwriters, Inc. A Surplus Lines Agency www.ciusgf.com 901 E. Saint Louis St. #205 Springfield, MO. 65806-2537
APPLICATION FOR LAWYERS PROFESSIONAL LIABILITY INSURANCE
(Claims Made and Reported Basis)
Applicant's Name
Agency Name
Address
Agent
Location
Email
Web Site Address
Phone
APPLICANT'S INSTRUCTIONS:
1. Answer all questions. If more details are required, please attach a separate sheet.
2. Application must be signed and dated by owner, partner or officer.
3. PLEASE READ CAREFULLY THE STATEMENTS AT THE END OF THIS APPLICATION.
1. APPLICANT INFORMATION
a.
Please list any secondary locations on a separate sheet and include number of lawyers at each location.
COMPLETE THE INSURED SUPPLEMENT
b.
(i)
Number of attorneys
(ii)
Number of Paralegals or law clerks
(iii)
Number of clerical or support staff
(iv)
Other-please describe
c.
Specify if:
Partnership
Corporation
Year established:
2. BUSINESS OPERATIONS
List on separate attachments the names of all predecessor firms whose assets and liabilities the Firm assumed during the past 10 years, include the name(s) of the firm(s), the year established, the number of lawyers, and the location.
Does the firm share or lease space with any other firm or entity?
No Yes
If so, please advise of the entity' name and the specific circumstances on a separate attachment.
Please advise of any foreign affiliated or associated firms and provide a detailed narrative of the name of the relationship on a separate attachment.
d.
Provide corporate brochure(s) and/or firm resume.
e.
Does any member of the Firm while rendering legal services also provide investment counselor services
or provide tax opinions on tax shelters?
If yes, please describe the nature of the services provided and the types of clients to which such services
are provided on a separate attachment.
Does any member of the firm on behalf of its clients perform legal services involving the formation or sale
of syndications or limited partnerships?
If yes, on separate attachment, describe services performed and details, including number of formed during
the past two years, total dollar amount of each and the nature of the investment.
f.
Indicate the approximate percentage of gross billable dollars from practice devoted to:
Admiralty/Maritime
%
Corporate (general)
Real Estate
Anti-Trust/Trade Reg.
Corp. Mergers/Acquisitions
Closings
Banking
Criminal
Escrow/Title
Bankruptcy
Domestic Relations
Syndication/Development
BI/PI Defendants
Entertainment
Securities Law*:
BI/PI Plaintiffs:
Estate/Probate/Trust
Federal SEC
Anticipated fees per case
International Law
State
less than $25,000
Labor
Private Placements
Litigation:
Bonds
greater than or equal to
Plaintiff
Taxation
$25,000
Defense
Preparation
Collection/
Municipal
Opinions
Repossession
Oil and Gas
Other**
Communications
Public Utilities
Copyright/Patent/TM
TOTAL INCOME:
100%
* Complete Securities Supplement.
** Over 5% Specify
g.
Are any major changes forseen in the percentage shown in question (f) for the current fiscal year?
If yes, please provide narrative details on a separate attachment.
h.
Specify the firm's total gross revenues:
Last fiscal year:
From to
Gross Revenues
$
Estimate current fiscal year:
i.
Is any lawyer listed in the Insured Supplement serving as a director, officer or partner of or exercising any
fiduciary control over any entity other than the firm?
If yes, complete the Outside Interests Supplement
REFER TO POLICY EXCLUSIONS REGARDING THESE ACTIVITIES
j.
Other than those positions referenced in question (i), does the firm or any lawyer or employee of the firm ever
invest in the business of a client?
If yes, please provide on separate attachment full details of such relationship.
k.
Except as listed in question i and j, does the firm or any of its members engage in any occupation, business
or profession other than the practice of law?
l.
Are custodial accounts (i.e., money, securities and other property held on behalf of clients) audited by an
independent, outside auditor?
Are two signatures required for all withdrawals of funds from custodial accounts?
m.
With respect to the total of all custodial accounts other than retainer fees, what is the average dollar amount and the maximum dollar amount held or maintained on behalf of the firm's clients?
Average: $
Maximum: $
n.
Does the firm maintain a fidelity bond covering all employees?
o.
Please describe by separate attachment the firm's procedures for the acceptance of new business including
conflict of interest checks and who has the authority to accept new business.
Does the firm make use of engagement letters with its new clients?
3. HISTORY
Over the past five years, has the Firm opened or closed any branch office or had a single loss of 25% or more
of the lawyers of the Firm?
If yes, please provide details by separate attachment.
Has the firm or any predecessor firm or any lawyer listed in the Insured Supplement ever had any
insurance company or Lloyd's decline, cancel, refuse to renew or accept only on special terms any
professional liability insurance?
If yes, please explain:
Has any lawyer listed in the Insured Supplement ever been the subject of a reprimand or disciplinary
action or refused admission to the Bar?
If yes, please explain on a separate attachment.
During the past seven years, has any professional liability claim or suit been made against any lawyer listed
in the Insured Supplement or against the firm or any predecessor firm?
If yes, a SUPPLEMENTAL CLAIM INFORMATION form must be completed for each claim.
After inquiry, does the firm or any person proposed for this insurance have knowledge of any incident,
circumstance, act, error, omission or personal injury which may give rise to a claim?
If yes, provide a complete description of each on a separate attachment. It is agreed that if there be
knowledge of any such incident, circumstance, error, omission or personal injury, any claim subsequently
emanating therefrom shall be excluded from coverage under the proposed insurance.
Please provide a list by separate attachment of all clients that represent 5% or more of the firm's total billable dollars or contribute
$1,000,000 or more to the firm's income annually.
List lawyers professional liability insurance carried for each of the past five years. IF NONE, STATE NONE.
Inception
Expiration
Insurance
Company
Policy
No.
Limit of
Liability
Deductible
Premium
From
To
NOTICE TO APPLICANT: The coverage applied for is SOLELY AS STATED IN THE POLICY, which provides coverage on a "CLAIMS MADE" basis for ONLY THOSE CLAIMS THAT ARE FIRST MADE AGAINST THE INSURED DURING THE POLICY PERIOD unless the extended reporting period option is exercised in accordance with the terms of the policy.
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 thereto commits a fraudulent insurance act, which is subject to criminal and civil penalties.
WARRANTY: I warrant to the Insurer, that I understand and accept the notice stated above and that the information contained herein is true and that it shall be the basis of the policy of insurance and deemed incorporated therein, should the Insurer evidence its acceptance of this application by issuance of a policy. I authorize the release of claim information from any prior insurer to Shand Morahan & Company, Inc., Ten Parkway North, Deerfield, Illinois 60015.
_____________________________________________
Name of Applicant
Title (Officer, partner, etc.)
Signature of Applicant
Date
SIGNING this application does not bind the Applicant or the Insurer or the Underwriting Manager to complete the insurance, but one copy of this application will be attached to the policy, if issued.
INSURED SUPPLEMENT
APPLICATION FOR LAWYER'S PROFESSIONAL LIABILITY INSURANCE
Indicate the names of all lawyers who are presently officers, partners, employed lawyer, of counsels or retired partners of the Firm and complete the requested information for each lawyer. Please not that coverage responds only for acts performed on behalf of the firm.
Name of Lawyers
Designation
O - Officer
P - Partner
E - Employed Lawyers
OC - Of Counsel
RP - Retired Partner
Member of
Management
Committee or
Governing Body
(Yes/No)
Year
Admitted to
Bar
Years of Full-
Time Practice
Specialty, if
any
Member in Good
Standing of the
Following State Bar(s)
I/We understand information submitted herein becomes a part of my/our professional liability application and is subject to the same representations and conditions.
Name of Applicant*
Title
*MUST BE SIGNED BY A MEMBER OF THE FIRM'S MANAGEMENT COMMITTEE OR GOVERNING BODY.
OUTSIDE INTERESTS SUPPLEMENT
FIRM:
% of Equity Interest
Name of Lawyer
Name of
Business
Position Held
Nature of
Individual
Firm & All
Lawyers and
Their Spouses
and Immediate
Family
Members
Combined
Client of
Applicant
D&O
Signature of Applicant*
SECURITIES SUPPLEMENT
(Complete Only if the Firm does Securities Offerings, Private Placements or Bond Work)
1.
Indicate the approximate amount of billable dollars derived from securities exempt and non-exempt work including federal SEC, state
securities, private placements and bonds: $
2.
Briefly describe your SEC practice qualifications including whether any lawyers of the Firm involved in such activities have in the past been SEC
staff members, practiced before the SEC or been cautioned or disqualified by the SEC. Provide narrative by separate attachment.
3.
(a)
Indicate by a check those procedures employed y the Firm in security (exempt and non-exempt) matters including private placements
and bonds:
Investigate client
Check on federal reporting systems
for prior criminal convictions
Investigate other participants
Court/regulatory investigation
Investigate other professionals
SEC filings filed and in order
Checklist
Check on tax opinion
On-site inspections
Render tax opinion
Review of corporate character
Check on prior injunctive actions in the SEC
Check on feasibility study
(b)
If the firm uses procedures other than those listed in 3(a) above, please describe by separate attachment.
4.
Using the chart below, list securities offerings (exempt and non-exempt), private placements and bond offerings handled in the past two
years including the year, name of insurer, type of transaction, type of business, underwriter, accountant, dollar size of offering and party
represented by Firm.
I/We understand information submitted herein becomes a part of my/our professional liability application and is subject to the same representation and conditions.
Issuer
Type of
Transaction
Indicate:
P = Private
Placement
F = Federal
Securities
S = State
B = Bond
Primary
Offering = 1
Subsequent
Offering = 2
Underwriter
Accountant
Dollar Size
of Offering
and
Description
of Security
Indicate Party
Represented by
Firm:
*I = Insurer
*U = Underwriter
L = Lender
IC = Insurance
Co.
P = Purchaser
Others - Specify
*Indicate by an Asterisk if acting as Bond Counsel.
SUPPLEMENTAL CLAIM INFORMATION FOR
LAWYERS PROFESSIONAL LIABILITY INSURANCE
3. This form is to be completed by Applicant who has been involved in any claim
or suit or aware of an incident which may give rise to a claim.
4. Complete one form for each claim or incident.
5. PLEASE READ CAREFULLY THE STATEMENTS AT THE END OF THIS APPLICATION.
APPLICANT INFORMATION
Firm Name:
Claimant Name:
Name of Individual(s) at Firm Involved in Claim:
Indicate whether:
Claim/Suit, or Incident
Date of alleged error:
Date of Claim:
Additional defendants:
IF CLOSED:
Total Loss Paid including Deductible:
Indicate whether Court judgment, or Out of court settlement
IF PENDING:
Claimant's settlement demand?
Defendant's offer for settlement?
Insurer's loss reserve?
Deductible?
Is claim in Suit?
No Yes If yes, Amount asked in summons? $
Name of Insurer:
Description of claim: (Provide enough information to allow evaluation, and use reverse side if additional space is required.)
Alleged act, error or omission upon which Claimant bases claim:
Description of case and events:
Description of the type and extent of injury or damage allegedly sustained:
Firm's evaluation of likelihood of liability:
Explain what action has been taken by the firm to prevent recurrence of the same type of claim.
DISCLOSURE
NOTICE OF TERRORISM
INSURANCE COVERAGE
AND ELECTION FORM
RE:
Risk ID. No.:
You are hereby notified that under the Terrorism Risk Insurance Act of 2002 (the "Act"), effective November 26, 2002, that you now have a right to purchase insurance coverage for losses arising out of acts of terrorism, as defined in Section 102(1) of the Act ("Terrorism Coverage"): The term "act of terrorism" means any act that is certified by the Secretary of the Treasury, in concurrence with the Secretary of State, and the Attorney General of the United States -- to be an act of terrorism; to be a violent act or an act that is dangerous to human life, property; or infrastructure; to have resulted in damage within the United States, or outside the United States in the case of an air carrier or vessel or the premises of a United States mission; and to have been committed by an individual or individuals acting on behalf of any foreign person or foreign interest, as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion.
You should know that Terrorism Coverage required to be offered by the Act for losses caused by certified acts of terrorism is partially reimbursed by the United States under a formula established by federal law. Under this formula, the United States pays 90% of covered terrorism losses exceeding the statutorily established deductible paid by the insurance company providing the coverage. The premium charged for this Terrorism Coverage is provided below and does not include any charges for the portion of loss covered by the federal government under the Act.
SELECTION OR REJECTION OF TERRORISM INSURANCE COVERAGE
PLEASE ENTER "X" IN ONE OF THE BOXES BELOW AND SIGN AND DATE WHERE INDICATED BELOW.
I hereby elect to purchase the Terrorism Coverage required to be offered under the Act. I understand that my policy premium will include a 3% surcharge for this coverage.
I decline to purchase the Terrorism Coverage required to be offered under the Act. I understand that my policy will be endorsed to exclude the Terrorism Coverage required to be offered under the Act.
SIGNING this Disclosure Notice does not bind the Applicant or the Insurer or the Underwriting Manager to complete the insurance.
TO COMPLETE YOUR APPLICATION, COMPLETE THESE TWO STEPS:
2. Hit this Submit button.
