LRS Errors and Omissions

Application for
LAWYER REFERRAL SERVICE ERRORS AND OMISSIONS INSURANCE
This is an application for Claims Made Insurance.

1. Name of Organization *

Address *

City *

State *

Zip Code *

Mailing Address

2. Date Organization Established +

Phone Number

Fax Number

Email Address

3. Name of Head Organization

4. Geographical Area of Service

5. Number of Attorneys on the Referral List

Number of Referrals Last Year

Estimated Number of Referrals This Year

6. List Branch Office and Addresses, if any

A.

B.

C.

7. How is Your Referral System Financed?

8. Explain Procedure for Renewal of the Attorneys on Your Referral List.

A. Do you check at least annually with the Lawyer Disciplinary Authority in your state for complaints against attorneys on referral list?

Yes

No

B. Does your plan contain unique features such as low fee panels, in court referral service, other special community programs?

Yes

No

If yes, please describe:

9. Does the organization receive a charge or fee for cases referred?

Yes

No

If yes, state the amount of charge and to whom said amount is charged

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).

Yes

No

If yes, please explain:

11. Has any errors or omissions claim ever been made against your organization?

Yes

No

If yes, please explain:

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?

Yes

No

If yes, please explain:

13. Limits applied for:

$250,000/$500,000

$500,000/$1,000,000

$1,000,000/$1,000,000

Deductible

$0

$500

$1,000

$2,500

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 _____________________