Application for “Claims Made” Policy
Applicant's Instructions:
ANSWER ALL QUESTIONS: If the answer to any question is None or Not Applicable, Please state "NO". If space is insufficient to answer any questions fully, attach a separate sheet. Application must be SIGNED and DATED by owner, partner or officer.

Note: All information disclosed on this application, together with any supplementary information regarding the applicant is considered to be privileged information, and will be held in strict confidence with the exception that it must be made available to Underwriters. It will not be released unless your written consent is given.
2. Type of Business:
3. Has the type of business changed in the last 5 years?
4. Has the name of Firm been changed during the past five years?
11. If Applicant is sole practitioner, state:

(a) Whether you are engaged in independent private practice
12. Does any lawyer named in Questions 6, 7 & 8 have any other law partner, associate, or employed lawyer other than those in Questions 6, 7 & 8?
13. Does any lawyer named in Questions 6, 7 & 8 share office space with any lawyer NOT NAMED in Questions 6, 7 & 8?
14. Describe your practice by first showing approximate amount of time devoted to the following:
(c) Total Areas of Practice (a+b)  =        100%

Describe "OTHER" below by showing percentages of time devoted to the following: (Your answer should equal the percentage shown above in 14. b)

*If adoption matters are dealt with, please give full details on a separate page.
** If your type of work includes Estate Planning, Estate/Probate/Trust, or Taxation, then please complete the Supplemental Tax Questionnaire.

16. Is the applicant currently insured under a Claims Made professional liability policy?
18. Please give full particulars of all similar insurances carried during the past five years:
 InsurerPremiumLimits of LiabilityDeductiblePeriodClaims Made or Occurrence Form
19. Has any professional liability insurance for the applicant, present Partner or predecessors or any lawyer in the firm ever been declined or cancelled, refused to be renewed?
20. After inquiry of each lawyer in the firm, has any lawyer in the firm ever been reprimanded by, or refused admission to practice, disbarred, or suspended from practice before any court or administrative agency or been subject to disciplinary actions?
21. After inquiry of each lawyer in the firm, have any claims or suits ever been made against any lawyer in the firm, or their predecessors in business?
22. After inquiry of each lawyer in the firm, does any lawyer in the firm know of any circumstances, act, error, omission or personal injury that could result in any claim being made against him/her or, their (his/her) predecessors in business or any of the present or past partners?
24. Applicants approximate gross billable dollars for the past 12 months are:
25. Does Applicant's practice also involve acting in the capacity of any of the following?
If so, indicate the percent of practice devoted to each and whether separate professional liability insurance is carried for this work:
26. Is/Was the applicant or any Partner or Lawyer of the Firm a salaried employee, partner, officer, director or owner of any organization other than the Firm?
27. Does (or did) the Applicant or any lawyer named in answer to Questions 6, 7 and 8 of the application ever provide legal services on behalf of clients with respect to Investment visas?

An Investment Visa is defined as: "A visa for alien entrepreneur which involves the investment of the alien's money in a business or business entity, including but not limited to a corporation, partnership, joint venture or sole proprietorship pursuant to Section 203(b)(5) of the Immigration and Naturalization Act, also codified at 8 U.S.C. 1153(b)(5), or which involves the investment of the alien's money in any other visa program which involves creation of employment in the United States."

28. Please provide the following information:    INSURANCE REQUESTED
(e) Enclose a sample of your retainer/agreement letter and letterhead

* Retroactive Date:  You may request the same Retroactive Date that is on your present policy if you have had continuous "claims made" coverage since that date.  If you are not currently insured by a "claims made" Lawyers Professional Liability Insurance Policy, then your Retroactive Date will be at Inception, which means no coverage will be afforded for any acts, errors or omissions committed, in whole or in part, prior to the Inception Date of any policy issued by Underwriters.


WARRANT:  I/We warrant 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 Underwriters evidence their acceptance of this application by issuance of a policy.  I/We hereby authorize the release of claim information from any prior insurer to Underwriters.  All information disclosed on this application, together with any supplementary information obtained regarding the applicant remains the exclusive property of CEM.

NOTE:  In applying for coverage, the applicant agrees that in the event of covered losses, he will be required to be defended by the Underwriters' appointed lawyers, and that the deductible shall apply to loss and claim expenses, adjusting expenses, investigation costs, and legal fees.  If the applicant elects to handle a claim without in any way involving the Underwriter, then no coverage for such claim is afforded the applicant under the policy.

I understand and accept that the policy applied for provides coverage on a CLAIMS FIRST MADE basis for ONLY THOSE CLAIMS FIRST MADE AGAINST THE ASSURED WHILE THE POLICY IS IN FORCE and that coverage ceases with the termination of policy unless I exercise options available and in accordance with terms of the policy.

AIF 2420 A (12/10)