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C & R INSURANCE SERVICES, INC

NEW YORK LAWYERS PROFESSIONAL LIABILITY
INSURANCE APPLICATION
THIS IS A CLAIMS-MADE APPLICATION 

THE POLICY  IS WRITTEN ON A DEFENSE WITHIN LIMITS BASIS

Claim Expenses charged against the limit of liability shall not exceed 50% of the limit of liability except for those applied against the deductible.  Claim expenses shall first be charged against the deductible up to 50% of the amount of the deductible. The Company shall assume Claim Expenses that exceed 50% of such deductible and 50% of the limit of liability.

   Download Application Form Here or Fill Out the Following to Submit Online
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.

Notice to Applicant – Please Read Carefully

THE APPLICANT REPRESENTS THAT THE ABOVE STATEMENTS AND FACTS ARE TRUE AND THAT NO MATERIAL FACTS HAVE BEEN SUPPRESSED OR MISSTATED.

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

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 FORM SHALL BE THE BASIS OF THE CONTRACT SHOULD A POLICY BE ISSUED, AND IT WILL BE ATTACHED TO THE POLICY.

Applicant hereby authorizes the release of claim information from any prior insurer to the Company indicated above.

The policy you are applying is subject to the following restrictions: no coverage for incidents prior to the retroactive date.  Except for the extended reporting period, there is no coverage for claims reported after the termination of coverage.  the automatic extended reporting period is sixty (60) days. rates for this policy are lower than an occurrence policy in the early years of the policy, but You should expect substantial rate increases.
_____________________________________________________________________________________

Signing this form and tendering premium does not bind the applicant or the Company to complete the insurance.  Application must be signed and dated to be considered for quotation.
 

NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud any Insurance Company or other person files an application for insurance or statement of claims 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.

NOTICE:

Failure to report: 

1.        any claim made against you during your current policy term, or

2.       any facts, circumstances or events which may give rise to a claim to your current insurance company BEFORE policy expiration may create a lack of coverage.
 
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