Application for
This is an application for Claims Made Insurance.

6. List Branch Office and Addresses, if any
A. Do you check at least annually with the Lawyer Disciplinary Authority in your state for complaints against attorneys on referral list?
B. Does your plan contain unique features such as low fee panels, in court referral service, other special community programs?
9. Does the organization receive a charge or fee for cases referred?
10. Does the organization perform any legal services for clients other than the referral of cases to lawyers? (Note: This insurance covers only errors and omissions while acting as a lawyer referral service as defined in the insurance).
11. Has any errors or omissions claim ever been made against your organization?
12. Are you aware of any allegations or contentions of any circumstance, act, error, omission or personal inquiry that could result in a claim against your organization or of any against an attorney relative to a case your organization has referred?
13. Limits applied for:
14. Quotation on cost of coverage will be provided based upon each individual application submitted.  Two to three weeks processing time is required.
15. I/We hereby declare, based upon my/our knowledge and upon reasonable investigation, the above statements and particulars are true and that I/We have not suppressed or misstated any material facts and this Proposal Form shall be the basis of the contract with the Underwriters at Lloyd's, London.
Date _______________   Signature _________________________________ Title _____________________