Application for
LAWYERS PROFESSIONAL LIABILITY INSURANCE
(This policy does not cover Private Law Practice)
This is an application for Claims Made Insurance.

SECTION I

1. Name of Organization *

Street Address

City

County

State *

Zip Code

Phone

Fax

Email Address

Website Address

Mailing Address

Date Organization established

2. List Branch Offices and Addresses, if any.
A.

B.

C.

List Subsidiary Offices and Addresses, if any.
2.A.

3.B.

3.C.

4. Type of Organization (Describe the purpose, general operations and functions of your Organization - if your Organization is strictly a pro bono or judicare Organization, please describe your operations under Question 8 below). (Use a separate page if necessary.)

5. Total number of cases and/or files handled or processed annually. (An estimate may be used if accurate count is not available).

6. Does the Organization accept cases for clients who are not indigent and whose incomes are above the national poverty level? (Written guidelines for client eligibility MUST be attached.)

Yes

No

7. If fees for services have been established by your Organization, please specify the type of case and the maximum fee charge presently used for each type of case (excluding registration fees and court costs). If no fees are charged, insert "Not Applicable".

8. Does your Organization provide services other than legal (social, medical, recreational or other)?

Yes

No

If YES, please attach written explanation.

9. Does your organization utilize the services of attorneys outside of your Organization on a pro bono, judicare or contract basis?

Yes

No

If YES, please respond to the questions below.

(a) Screening and referral is performed by:

(b) Types of matters referred:

(c) Number of pro bono/judicare panel attorneys:

Number of pro bono/judicare cases referred annually:

Number of attorneys accepting reduced-fee referrals (fee paid by client):

Number of reduced-fee referrals annually (attach fee schedule):

Number of contract attorneys:

Number of cases handled on a contract basis:

(d) Does your organization check to see if the participating attorneys are admitted to practice law in your state?

Yes

No

(e) Does your organization check to see if the participating attorneys have had any legal malpractice or disciplinary complaints filed against them?

Yes

No

(f) Does your organization inform the client and the participating attorney of the terms and conditions of the referral (e.g. the termination of representation by your organization)?

Yes

No

(g) Please describe your organization's monitoring and follow-up procedures (Send separate correspondence.)

PRO BONO ENDORSEMENT COVERAGE

If you answered YES, you can extend coverage for your organization and your outside attorneys. Please select one of the endorsement options below, and your quotations will include the premium for the endorsement you select.

Coverage For Attorneys and Case Referrals

STANDARD PRO BONO/JUDICARE FOR ATTORNEYS AND CASES: Provides coverage to your organization for the referral of legal aid eligible clients/cases to participating pro bono/judicare/contract attorneys. Coverage A will also extend to the participating attorneys handling the pro bono/judicare cases referred by your organization. This coverage is secondary to any other valid and collectible insurance available to such attorneys.

PRIMARY PRO BONO/JUDICARE FOR ATTORNEYS ONLY: The same as Standard above except that the coverage would be considered Primary and all other insurance would be considered in excess thereto.

PRIMARY PRO BONO/JUDICARE FOR ATTORNEYS AND THEIR EMPLOYER FIRMS: The same as Standard above except that the coverage would be considered Primary and all other insurance would be considered in excess thereto. In addition, the coverage would extend to any law firm, corporation, or other organization which an attorney accepting a case is an employee or member of. Coverage for the employer firm would be limited solely with respect to liability arising from the participation of the attorney in the pro bono/judicare program.

REFERRALS ONLY COVERAGE: Provides your organization with coverage for referral of eligible clients to a pro bono/judicare program outside of your organization. There is no coverage for any attorney accepting the referral.

We do not wish to carry any pro bono endorsement

10. Describe your Organization's practice of law by showing approximate percentages of cases involving the following:

(Total should equal 100%)

Divorce/Family Law

Labor

Real Estate

Environmental Law

Bankruptcy

Immigration

Landlord/Tenant

Housing Law

Wills/Estate Work

Bonding Issues (and related work)

Public Benefits Law
(Social Sec., Unemployment
Comp., Workmen's Comp.,
Medicare)

Advocacy for Developmentally and/or
Mentally Disabled Persons

Guardianships

Child/Spouse Abuse

Criminal

Services to farmers regarding creation,
adjustment, restructuring or discharge
of indebtedness secured by farm real
estate or crops

Juvenile

Corporate

Bodily/Personal Injury
Plaintiff

Defendant

Other (please Specify)

.

Other (please Specify)

.

Other (please Specify)

.

11. Does your Organization provide legal services to groups, corporations or associations?

Yes

No

If YES, please provide detailed description (types of groups/corporations/associations, specific legal services provided, etc.) (Use additional sheet, if necessary)

12. If you have answered YES to Question 11, please indicate whether the group, corporation or association is primarily composed of persons eligible for legal aid services and whether such group, corporation or association has provided information showing it lacks and has no practical means of obtaining funds to retain private counsel.

13. Please indicate position after the name of each individual listed and whether the individual is salaried or volunteer and part-time or full-time. Please also indicate if any of the individuals listed below are located in states other than where the main office is located.

	LAWYERS	LAW STUDENTS/PARAPROFESSIONALS
.	LAWYERS	LAW STUDENTS/PARAPROFESSIONALS
.	LAWYERS	LAW STUDENTS/PARAPROFESSIONALS
.	LAWYERS	LAW STUDENTS/PARAPROFESSIONALS
.	LAWYERS	LAW STUDENTS/PARAPROFESSIONALS
.	LAWYERS	LAW STUDENTS/PARAPROFESSIONALS
.	LAWYERS	LAW STUDENTS/PARAPROFESSIONALS
.	LAWYERS	LAW STUDENTS/PARAPROFESSIONALS

14. Is your organization an ACLU that utilizes the services of cooperating volunteer attorneys outside of your organization?

Yes

No

If YES, please advise maximum number of such attorneys

and maximum number of cases handled.

15. Does your organization permit attorneys to engage in uncompensated outside practice of law as defined in the Legal Services Corporation regulations?

Yes

No

16. Has any claim, suit, charge, investigation or proceeding ever been made or instituted against the Organization or any Lawyer or other person providing professional services on behalf of the Organization which (Please check appropriate box):

Seeks an injunction or functionally similar order (including but not limited to a restraining order, a writ of mandamus, a writ of prohibition or an order compel prosecution)?

Yes

No

Alleges any of the following types of conduct listed on the next page:

(a) Negligent acts or omissions in the course of rendering professional services as a Lawyer, under the direction of a Lawyer, or Notary Public?

Yes

No

(b) Attorney misconduct or breach of professional ethics?

Yes

No

(c) False arrest, detention or imprisonment or malicious prosecution?

Yes

No

(d) Publication or utterance of a libel or slander or of any other defamatory or disparaging material or publication or utterance in violation of an individual’s right of privacy?

Yes

No

(e) Wrongful entry or eviction, or other invasion of the right of private occupancy?

Yes

No

(f) Conduct for which the claimant seeks an award of punitive or exemplary damages?

Yes

No

(g) Violation of a federal, state, municipal or local criminal statute or law?

Yes

No

(h) Conduct which may give rise to a contempt proceeding?

Yes

No

(i) Any conduct in connection with the employment, hiring, failure to hire, discharge or termination of the employment of an employee, former employee or application for employment?

Yes

No

(j) Conduct of Directors/Officers and/or other management personnel alleging negligence in their official capacity as management?

Yes

No

17. Does the Organization or any person specified in response to Question 12 know of any circumstance, act, error, omission or inquiry that could result in a claim, suit, charge, investigation or proceeding against the Organization or any Lawyer or other person providing professional services on behalf of the Organization that seeks an injunction or functionally similar order or is based on any of the types of conduct described in Question 15 above?

Yes

No

If YES, please provide the name of the Lawyer or other person involved and all other pertinent details (use a separate sheet if necessary).

18. Current Lawyers Professional Liability Insurance (must be completed in full):

(a) Carrier:

(b) Limits of Liability:

(c) Deductible:

(d) Policy Expiration Date:

(e) Premium:

(f) Retroactive Date: Please attach a copy of your current policy.

19. Does you organization provide legal services to farmers regarding the creation, adjustment, restructuring or discharge of indebtedness secured by farm real estate or crops?

Yes

No

If YES, please provide details.

If YES, do you charge fees to the recipient client directly for the services rendered?

Yes

No

SECTION II - DATE, CALENDAR OR DOCKET CONTROL AND INTERNAL PROCEDURES

1. Does your Organization...

- have at least two independently maintained calendars on which litigated and non-litigated items are entered by separate individuals?

Yes

No

AND are the calendars cross-checked at least weekly by separate individuals responsible for cross-checking?

Yes

No

AND does ultimate responsibility for docket control rest with the attorney responsible for the case?

Yes

No

If any of the above answers are NO, please explain on a separate sheet.

2. Does your organization use a computer-driven calendar and docket control system?

Yes

No

Name of software program

3. If your organization becomes aware of a conflict, do you disclose it in writing to all parties?

Yes

No

If NO, please explain

4. Does your Organization have written procedures for identifying potential or actual conflicts of interest?

Yes

No

If NO, please explain

5. How does your Organization avoid conflicts of interest?

	Yes	No
Oral/memory	Yes	No
Index file	Yes	No
Computer	Yes	No
Conflict Committee	Yes	No
Other	Yes	No

If other, please list

.

6. Does your Organization generate engagement letters for all its clients?

Yes

No

7. Does your Organization notify clients in writing when your services are completed and when a relationship is terminated?

Yes

No

If NO, please explain

8. Does your Organization notify clients or prospective clients in writing when you decline to represent them?

Yes

No

If NO, please explain

9. Does your Organization have an internal grievance procedure to address complaints by clients?

Yes

No

If YES, please attach a description.

SECTION III

1. What constitutes the management of the Organization? (Trustees, Directors' Committee, Titles of Officers, etc.)

2. How is Management selected?

3. Staff

.

	Salaried	Non-Salaried
Number of officers and/or directors (including Executive Director)	Salaried	Non-Salaried
Number of Staff members (not including clerical employees)	Salaried	Non-Salaried
Number of clerical employees	Salaried	Non-Salaried

Is the Executive Director full-time or part-time?

Full-time

Part-time

4. Is the Organization a Not-for-Profit corporation chartered in its state of domicile?

Yes

No

If NO, Please explain its status.

5. Is the Organization directly in the insurance agency or brokerage business in any way?

Yes

No

If YES, please explain.

6. Is your Organization unionized?

Yes

No

7. Does your organization have an internal grievance procedure to address complaints by employees?

Yes

No

If YES, please attach a description.

8. Does the Organization publish any publication for limited or general distribution?

Yes

No

If YES, please attach sample of each.

a. As to each publication, state its purpose, general content, frequency of publication and amount published (use a separate sheet if necessary).

b. State the name of the officer or employee who reviews each publication prior to its distribution.

9. Does the Organization sponsor any private or public meetings or conventions?

Yes

No

If YES, please state number and frequency.

10. Total Annual budget (all sources) Year

.

LSC (Legal Services Corporation) Budget

IOLTA

Title XX

United Way

Older Americans Act

Other Sources*

= TOTAL BUDGET

*Please identify other funding sources