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Attorneys Liability Insurance Application - Scottsdale Business

By Stephen Green,2014-07-09 19:49
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Attorneys Liability Insurance Application - Scottsdale Business ...

    PROFESSIONAL LIABILITY INSURANCE FOR LAW FIRMS

    APPLICATION

    NOTICE: This professional liability coverage is provided on a Claims Made basis. Only claims that are first made against the insured

    and reported to the Company during the policy term are covered, subject to the policy provisions.

    Applicant Instructions: Carefully read all statements and questions on this application. Answer all questions in ink. If a question does

    not apply, state “N/A”. If space is insufficient to answer all questions fully, use separate sheets of paper. Application and all attachments

    must be signed and dated by named applicant, partner or officer. A copy of your business stationery must be attached. Effective Date Requested For This Application _____________ / _________ / _________

    Limits of Liability Desired: $ Deductible Desired $

    1. a. Name of Applicant (Firm Name): ______________________________________________________________________________

     b. Name of Designated Contact: ________________________________________________________________________________

     c. Physical Address: _________________________________________________________________________________________

     (Street) (City) (County) (State) (Zip)

     d. Telephone Number: (______)________________ Facsimile Number: (_____)____________________ 2. Date Firm Established _______/_______/_______

    Applicant is: ___ Sole Proprietor ___ Professional Association ___ Partnership 3.

     ___ P.C. ___ LLC ___ Other (please describe) 4. During the past six (6) years, has the number of lawyers in the firm been altered by more than 30% in any one Yes No year? If Yes, provide additional information on the Detail Information Addendum. ..................................................... 5. List all predecessor firms of Applicant. If not applicable, state N/A. A predecessor firm is any legal entity, which is engaged in the practice of law to whose financial assets and liabilities the applicant is the majority successor in interest.

     Name of Firm Date Established Date of Merger

    Does the applicant: 6.

    a. have any additional office locations? ................................................................................................................... Yes No

     Yes No b. share office space with lawyers who are not a part of the applicant firm? .............................................................

     c. share secretarial service/staff with others who are not a part of the applicant firm? ............................................... Yes No

     d. share letterhead with non-firm members? ........................................................................................................... Yes No

     If Yes to any of the above, provide details on the Detail Information Addendum and supply a sample of the letterhead.

    If the Applicant is a sole practitioner, is a backup lawyer available in the applicant's absence? ........................................... Yes Yes No No 7. Name and address of backup attorney: __________________________________________________________

     _________________________________________________________________________________________ _________________________________________________________________________________________

    Number support staff: ____ Law clerk/paralegal ____ Secretarial/clerical Other: ______________________ 8.

     If ratio of staff to attorneys is greater than 2:1, provide details on the Detail Information Addendum.

    9. List below, all LAWYERS of the firm. Attach a separate sheet if additional space is required. “O” Owner/Officer/Director “P” Partner “E” Employed lawyer “OC” Of Counsel “IC” Independent Contractor LCP700 (6/08) ? The Medical Assurance Company, Inc. Page 1 of 6

     States of Year Date of hire with Number hours CLE in Name of Attorney Designation Admission Admitted applicant or predecessor firm the past 12 months

     If additional space is needed, complete the Attorney Detail Supplement. 10. Complete the following for each Of Counsel, Independent Contractor or Per Diem hired by the firm.

    Hours worked per Separate Professional Name of Attorney Designation Date of Hire week for applicant Liability Insurance?

     Yes No

     Yes No

     Yes No

11. Is any lawyer proposed for this insurance an employee of any organization other than the applicant? ................................ Yes No If Yes, provide details on the Detail Information Addendum.

    12. Has any lawyer proposed for this insurance provided any professional services as an Accountant, Realtor,

    Investment Advisor, Insurance Agent, Professional Agent or other non-legal capacity? ......................................................Yes No If Yes, provide details on the Detail Information Addendum.

    13. Does any lawyer proposed for this insurance:

    a. act as a director, officer, partner or trustee for, or exercise any form of managerial or fiduciary control Yes No over, any business enterprise of a client other than the applicant? ....................................................................

     b. own, manage, have financial control over, or equity interest in, any business enterprise of a client other

    than the applicant or its predecessor firms? ................................................................................................Yes ........ No If Yes to a or b above, complete the Outside Interests Supplemental Application.

     14. Has any lawyer proposed for this insurance ever been denied the right to practice, suspended from practice, disbarred, reprimanded or had other disciplinary action taken against him or her by any court or administrative Yes No agency? If Yes, provide details on the Detail Information Addendum. ............................................................................... 15. List All Lawyers Professional Liability Insurance carried during the past consecutive five (5) years for the applicant and/or any predecessor firm thereof. If no current coverage is in force, check the box:

     Insurance Annual Number Policy Inception Policy Expiration Policy Limits Deductible Company Premium Attorneys

     16. Insurance Details:

     a. Inception date of the applicant’s first continuous claims made professional liability insurance: ......................____________

    Yes No b. Does the current policy have a retroactive/prior acts date applicable to the applicant? ...................................

    ____________ If Yes, provide exact date. .........................................................................................................................

     Yes No c. Does the current policy have any limiting endorsements or exclusions? .............................................................. If Yes, provide details: ________________________________________________________________

     d. Has the applicant, its predecessor firms, or any lawyer proposed for this insurance, purchased an

    Extended Reporting Period (ERP) Endorsement? ...............................................................................................Yes No

     If Yes, please complete: Effective from _____/_____/_______ to _____/______/_______

    Indicate the percent of the Applicant's income derived from the following types of practice. (MUST TOTAL 100%) 17.

     DEFENSE % Ad Valorem Tax Commercial Provide Additional Information* %

     Admiralty Ad Valorem Tax Residential Corporate General LCP700 (6/08) ? The Medical Assurance Company, Inc. Page 2 of 6

     Arbitration / Mediation Administrative Law Environmental

     BI/PI Adoptions Fiduciary

     Civil Rights / Employment Antitrust Trade Regulations Investment Cnsling / Money Mgt

     Class Action / Mass Tort Bankruptcy Mergers & Acquisitions

     Commercial Litigation Collection Oil and Gas

     Criminal Communication Other:_____________________

     Insurance Company Construction Venture Capital

     Medical Malpractice Corporation Formation

     Product Liability Divorce Complete Additional Supplement

     Workers Compensation Estate Planning Abstracting / Title

     ERISA Banking / Financial Institutions

     PLAINTIFF (complete supplement) Family Law (other than Divorce) Bonds

     Admiralty Foreclosures Copyright

     BI/PI Plaintiff Health Entertainment

     Civil Rights / Employment Housing Court Limited Partnerships

     Class Action / Mass Tort Immigration Patent

     Commercial Litigation International Private Placements

     Medical Malpractice Labor Employee / Union Real Estate Residential

     Product Liability Labor Management Real Estate Commercial

     Workers Compensation Local Government / Municipal Real Estate Development

     Public Utilities Securities Federal

     TAX Individual Preparation Social Security Securities State

     TAX Commercial Preparation Water Law Syndications

     TAX Opinions Wills and Trusts Trademark

     * Provide additional information on the Detail Information Addendum or complete the appropriate supplement.

18. Within the past six (6) years has the applicant or any attorney proposed for this insurance:

    a. Provided any legal services for or on behalf of any financial institution? ............................................................... Yes No

     b. Provided any legal services for or in connection with any IPO, Bond, Private Placement, Syndication or any Securities related matter? ............................................................................................................................ Yes No

     c. Provided any legal services for or on behalf of any Class Action matter? ............................................................. Yes No

     d. Provided any legal services for any Entertainment client or the Entertainment industry? ....................................... Yes No

     e. Provided any legal services for or in connection with any Copyright, Patent or Trademark matter? ................................Yes No ............

     f. Provided any legal services for or in connection with any Environmental matter? ................................................................Yes No ......

     If Yes to any of the above, complete the appropriate Supplement.

    19. Do you require Title Insurance Coverage? ........................................................................................................................ Yes No

    _________ a. Number of lawyers who are Title Agents: ......................................................................................................... ___________ b. Name of Title Company Represented: _____________________________________________________________________ c. Do you require coverage for a Title Agency (provide name)? ___________________________________________________ d. If Yes, is the agency wholly owned by the firm and/or its members? ......................................................................................... Yes No

     20. Gross Revenue for the past three (3) years:

     Most Recent Twelve (12) months One (1) Year Prior Two (2) Years Prior

    21. Yes No Within the past six (6) years, has any one client generated 20% or more of gross revenue? ....................................................................

    If Yes, complete the following table.

     Name of Client Services Provided Percentage of Gross Revenue

    LCP700 (6/08) ? The Medical Assurance Company, Inc. Page 3 of 6

     22. Docket/Diary Control System:

    a. Do you maintain a central docket control system? .............................................................................................Yes No b. Does the applicant have at least two (2) methods for docket control?................................................................Yes ... No c. Does the applicant utilize a computer program for docket control? ................................................................Yes ....... No d. Does the ultimate responsibility for docket control, including entry, rest with the handling lawyer?.........................Yes No

    Yes No e. Does the applicant crosscheck its docket controls? ............................................................................................. f. If Yes, how frequently? ............................................................................................................................... __________ If No, provided details on the Detail Information Addendum.

    23. How many suits for fees were initiated by the Applicant against clients during the past 24 months? ............................. _________ ______________ a. How many have been resolved? .................................................................................................................. _________ ______________

    _________ b. What percentage of fees are more than 90 days past due? .......................................................................... ______________

    _________ c. How frequently are invoices provided to clients?........................................................................................... ______________

     24. Does the applicant utilize the following for ALL clients? Yes No a. Engagement letters that include the scope of services & fee arrangements? ....................................................... Yes No Yes No b. Non-engagement/declination letters? ................................................................................................................. Yes No Yes No c. Disengagement/closing letters? .......................................................................................................................... Yes No If No, provide details on the Detail Information Addendum.

    25. Does the applicant maintain a conflict of interest avoidance system?.................................................................................Yes Yes No No If No, provide details on the Detail Information Addendum. a. Systems used to check conflicts of interest: ________________________________________________________________ b. How frequently are checks made for conflicts of interest? ______________________________________________________ c. How are conflict of interest situations addressed and disclosed to clients/potential clients? Check all that

    apply.

     Non-Engagement Letters Signed Waiver Obtained from all parties

     Oral Disclosure to all parties Referral to other lawyer / law firm

    26. Does the applicant communicate with clients by electronic mail? ...................................................................................... Yes No a. If Yes, are records maintained of all electronic mail communications? ................................................................. Yes No Yes No

    Yes No b. Does the firm have guidelines restricting the types of communication over the internet? ...................................... Yes No

    27. Does the applicant have a website? ................................................................................................................................ Yes No Yes No If Yes, provide the Web Address: ___________________________________________________________

    Yes No a. Does the website offer legal advice? ..........................................................................................................

    Yes No b. Does the applicant collect sensitive or confidential information at the web site? ................................................... Yes No

    Yes No c. Is all information collected kept confidential? ....................................................................................................... Yes No

    Yes No c. Does the applicant have a firewall installed to protect the network and prevent hacker attacks?............................ Yes No Yes No d. Does the applicant have virus-detecting software installed to protect against viruses? .......................................... Yes No Yes No e. Does the applicant have back-up and recovery systems in place? ...................................................................... Yes No

     28. Has any application for Lawyers Professional Liability Insurance on behalf of the applicant, its predecessor firms or any lawyers proposed for this insurance been declined, policy canceled or renewal of such insurance been Yes No refused? .......................................................................................................................................................................... Yes No If Yes, provide details on the Detail Information Addendum.

     29. During the past five (5) years, has any claim or suit been filed against the applicant, its predecessor firms or any of Yes No the lawyers proposed for this insurance? .......................................................................................................................... Yes No

    _________ If Yes, complete a Claim Supplement for each claim or suit. Number?

    LCP700 (6/08) ? The Medical Assurance Company, Inc. Page 4 of 6

    30. After inquiry, is the applicant, its predecessor firms or any lawyer proposed for this insurance aware of:

    a. any circumstance, act, error, omission or personal injury which could be the basis of a claim or suit? ............. Yes No

    b. any potential malpractice claim or suit reported to a previous insurance carrier? ..................................................... Yes No

    c. any adverse judgment that could be the basis of a claim or suit? ............................................................................ Yes No

     d. any missed statute of limitations? .......................................................................................................................... Yes No If Yes to any of the above, complete a Claim Supplement for each. Number? _________ NOTICE: To avoid loss of coverage, it is imperative that all known claims and/or circumstances, acts, errors or personal injuries that could result in a professional liability claim against the applicant, its predecessor firms or any lawyers in the firm be reported to your current insurer within the time period specified in your current policy.

    The undersigned represents and warrants that the statements set forth herein are true, complete and accurate and that there has been no attempt at suppression or misstatement of any material facts known, or which should be known, and agrees that this application and all supplements and attachments hereto shall become the basis of any coverage and a part of any policy that may be issued by the Company.

    The execution of this application does not bind the undersigned to purchase any coverage offered, nor does the receipt and or review of this application bind the Company to offer coverage or issue a policy.

    The undersigned understands and accepts that any policy issued will provide coverage on a Claims Made and Reported basis. Warning: Any person who knowingly and with intent to defraud any insurance company or other person, files an application

    for insurance 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 subjects the person to criminal and civil penalties.

    Notice To Arizona Applicants:

    For your protection, Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.

    Notice To California Applicants:

    For your protection California law requires the following to appear on this form. Any person who knowingly presents false or

    fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in prison. Any

    person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

    Notice to Colorado Resident Applicants:

    It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the

    purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance

    and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

    Notice To Delaware Applicants:

    Any person who knowingly, and with the intent to injure, defraud or deceive an insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony.

    Notice To District Of Columbia Applicants:

    It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, any insurer may deny insurance benefits if false information

    materially related to a claim was provided by the applicant.

    Notice To Indiana Residents:

    A person who knowingly and with the intent to defraud an insurer files a statement of claims containing any false, incomplete

    or misleading information commits a felony.

    Notice To Nevada Applicants:

    Pursuant to NRS 686A.291, any person who knowingly and willfully files a statement that contains any false, incomplete or misleading information concerning a material fact is guilty of a felony.

    Notice To New Jersey Applicants:

    Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal

    and civil penalties.

    Notice to Ohio Resident Applicants:

    Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

    LCP700 (6/08) ? The Medical Assurance Company, Inc. Page 5 of 6

Notice To Pennsylvania Applicants:

    Any person who knowingly and with the 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 thereto commits a fraudulent insurance act, which is a crime and subjects such a person to criminal and civil penalties.

    Notice To Virginia Applications:

    It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of

    defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

    APPLICANT’S AUTHORIZATION AND CERTIFICATION The undersigned on behalf of the applicant firm and all members of the firm authorizes the release of all information to the

    Company from any past or present bar association of which any member of the firm is currently or has been a member; any

    person(s) who has information concerning any firm member’s fitness to practice; any insurance company to which the

    applicant firm or any member of the firm has applied for professional liability insurance, whether such coverage was

    granted or not; and any employer for whom any member of the firm performed legal services, whether as an employee or an independent contractor.

The applicant firm and all members of the firm understand that the information requested by the Company may include, but

    not necessarily be limited to, any occurrence, incident, claim or suit in which any member of the firm may be or may have

    been involved; any denial, suspension, revocation or other disciplinary action taken by any bar association, governmental

    licensing authority, court, administrative agency or other appropriate authority; or any action of a civil or criminal nature taken against the firm or any member of the firm that resulted from or was alleged to have been a part of any professional

    activities. The applicant firm and all members of the firm understand that the information will be used in addition to the application in determining whether the Company will issue insurance to the firm.

The applicant firm and all members of the firm agree that the persons providing the information and their agents, directors

    and employees, shall not incur any liability as a result of any information released in good faith pursuant to this

    authorization including any errors, omissions or mistakes contained in such information.

The applicant firm and all members of the firm understand that this is an application for insurance, and shall not bind the

    Company to the issuance of insurance, nor shall it bind the firm to the acceptance of a policy.

THE UNDERSIGNED ON BEHALF OF THE APPLICANT FIRM AND ALL MEMBERS OF THE FIRM CERTIFIES THAT

    THE ABOVE APPLICATION HAS BEEN READ AND THAT ALL STATEMENTS MADE IN THIS APPLICATION ARE

    TRUE, MATERIAL AND COMPLETE. THE UNDERSIGNED UNDERSTANDS THAT: (1) IF THE POLICY IS ISSUED,

    THIS IS DONE BY THE COMPANY IN RELIANCE UPON THESE REPRESENTATIONS; AND (2) ANY COVERAGE OBTAINED BY FRAUD, MATERIAL MISREPRESENTATION OR OMISSION IS VOID.

Signature of Partner, Officer or Owner _____________________________________________ Date ___________________

Print or Type Name_____________________________________________________________ Title_____________________

    Firm Name ___________________________________________________________________

LCP700 (6/08) ? The Medical Assurance Company, Inc. Page 6 of 6

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