Insuring Lawyers| Attorneys Advocate program, professional liability insurance law, and contemptible public liability insurance

Firm/ Applicant Name* :

Email Address :

Principal Business Address :

Phone :
Fax :
Effective Date Requested :

City :

State :

County :

Zip :

Please List all the attorneys practicing on behalf of your firm. Add attachments if necessary

Attorney Name	Social Security Number	Years in private practice	Designation Code		Current Legal Malpractice Insurance Carrier	Retroactive Date

Designation Code : E = Member/Employee of the Firm, OC = Of Counsel/Independent Contractor and F= Full Time, P= Part Time ( 26 hours or fewer per week)

Have any members of your firm been reprimanded, censured, suspended or disbarred within the past five (5) years?
If YES, provide full details on your letterhead.

Yes No

Have any professional liability claim(s) or suit(s) been made against the applicant firm or any attorney(s) in the applicant firm or former attorney(s) in the applicant firm within the past five years?
If YES, complete the Claim Supplemental Application.

Yes No

After inquiry, are you or any attorney in your firm aware of any circumstances, incidents, acts or omissions that has led to a professional liability claim that has not yet settled or which could lead to a professional liability claim being made against your firm?
If YES, complete the Claim Supplemental Application.

Yes No

Current Limit of Liability :

Limits Desired :

Current Deductible :

Deductible Desired :

Expiring premium :

Please provide the percentage of the gross billable dollars allocated to each area of practice. Please round to the nearest whole number. Total must be equal to 100%.

ADMIRALTY/MARITIME		GOVERNMENT-FEDERAL AND STATE
ANTITRUST		GOVERNMENT-LOCAL (NOT BOND WORK)
BUSINESS TRANSACTIONS-CORPORATE AND COMMERCIAL		IMMIGRATION/NATURALIZATION
BUSINESS TRANSACTIONS-ENTERTAINMENT		INTERNATIONAL LAW
CIVIL RIGHTS/DISCRIMINATION		LABOR LAW
COLLECTION/BANKRUPTCY		PI/PD-PLAINTIFF
CONSTRUCTION LAW (BUILDING CONTRACTS)		INSURANCE DEFENSE
CONSUMER CLAIMS		WORKERS COMPENSATION-DEFENSE
BUSINESS ORGANIZATION		WORKERS COMPENSATION-PLAINTIFF
Formation/Alteration and Mergers/Acquisitions		NATURAL RESOURCES/OIL & GAS
Secured Transactions		PATENT/TRADEMARK/COPYRIGHT (INTELLECTUAL PROPERTY)
Administrative Law/Record Keeping		REAL ESTATE
CRIMINAL		SECURITIES LAW State or Federal (both exempt and registered)
ENVIRONMENTAL LAW		Municipal Bonds
ESTATE/TRUST/PROBATE		TAXATION/TAX OPINIONS
FAMILY LAW		TOTAL :

BOLD INDICATES THAT A SEPARATE SUPPLEMENTAL APPLICATION IS REQUIRED.

The applicant represents that the above statements are true and correct to the best of his or her knowledge and that no material or relevant facts have been suppressed or misstated and agree that the policy, if issued, will be issued on the reliance of such representations.

Applicant acknowledges a continuing obligation to report to us as soon as practicable any material changes in the facts or statements above, and in each supplementary application, which applicant becomes aware after signing the application.

Notice to Applicant: 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 false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime in certain jurisdictions.

Completion of this form does not bind coverage. Applicant’s acceptance of company’s quotation is required prior to binding coverage and policy issuance. It is agreed that this application shall be the basis of the contract of insurance should a policy be issued and it will be attached to the policy.

Date
Print Name
Title