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                                                                                                INSTRUCTIONS                                R-Civil
 

LAWYERS PROFESSIONAL LIABILITY INSURANCE


  1. Answer ALL questions and submit copies of all information where requested. Incomplete applications will result in a delay in obtaining a quotation and possible lapse in coverage.
  1. Please be sure to send separate correspondence for any additional information requested.
  1. In responding to Section I, Question 13, list the current and projected staff of your organization and indicate the title of each individual (i.e. executive director, lawyer, volunteer attorney, managing attorney, staff attorney, law student, paralegal, etc.). The executive director position must be listed regardless of whether that individual is an attorney.  It is not necessary for you to list persons holding clerical positions.  Projected positions should be indicated by using the term "To Be Filled".  PLEASE NOTE THAT A REDUCTION OF PERSONNEL WILL NOT RESULT IN RETURN OF PRO RATA PREMIUM DURING THE POLICY YEAR.
  1. If you need to clarify any of the answers to any question or require additional space, please feel free to send addendums.
  1. Please sign and date the application.
  1. If you answer "Yes" to Question #9 of Section III, please be sure to send descriptions.
  1. Please submit the application by the DEADLINE FOR RETURN OF APPLICATIONS SHOWN ON THE EXPIRATION NOTICE.
This date is provided to ensure that renewal of your coverages can be completed before the DATE OF EXPIRATION.  Underwriters require up to 14 days to review and quote assuming all required information for quoting has been supplied.  Any applications not received by the deadline for return of applications as shown on the expiration notice may result in a lapse in coverage.

PLEASE NOTE:  THIS COVERAGE IS "CLAIMS MADE" INSURANCE.  SHOULD YOUR ORGANIZATION FAIL TO PURCHASE COVERAGE BEFORE THE EXPIRATION DATE SHOWN ABOVE, THERE WOULD BE NO COVERAGE FOR ANY CIRCUMSTANCE LIKELY TO GIVE RISE TO A CLAIM OR ANY CLAIM MADE AGAINST YOU, REGARDLESS OF WHEN THE ORIGINAL ACT, ERROR OR OMISSION OCCURRED, UNLESS, PURSUANT TO THE POLICY TERMS AND CONDITIONS, 1) YOU GIVE WRITTEN NOTICE OF THE CIRCUMSTANCE THAT MAY GIVE RISE TO A CLAIM AGAINST YOU TO UNDERWRITERS ON OR BEFORE THE EXPIRATION DATE OR 2) THE CLAIM IS ACTUALLY MADE AGAINST YOU ON OR BEFORE THE EXPIRATION DATE AND YOU GIVE IMMEDIATE WRITTEN NOTICE TO UNDERWRITERS.

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

SECTION I
0/650 characters
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.)
0/650 characters
8. Does your Organization provide services other than legal (social, medical, recreational or other)? If YES, please send written explanation
9. Does your organization utilize the services of attorneys outside of your Organization on a pro bono, judicare or contract basis?
If YES, please respond to the questions below.
(d) Does your organization check to see if the participating attorneys are admitted to practice law in your state?
(e) Does your organization check to see if the participating attorneys have had any legal malpractice or disciplinary complaints filed against them?
(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)?
(g) Please describe your organization's monitoring and follow-up procedures (Use a separate attachment.)
 
 
Describe your Organization's practice of law by showing approximate percentages of cases involving the following:
(Total should equal 100%)
 
10. Does your Organization provide legal services to groups, corporations or associations?
0/450 characters
0/450 characters
12. Attorney/Staff Information    
 
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 above are located in states other than where the main office is located.
 LAWYERSLAW STUDENTS/PARAPROFESSIONALS
1
2
3
4
5
6
7
8
9
10
13. Is your organization an ACLU that utilizes the services of cooperating volunteer attorneys outside of your organization?
14. Does your organization permit attorneys to engage in uncompensated outside practice of law as defined in the Legal Services Corporation regulations?
15. In the last 5 years, has any claim, suit, charge, investigation or proceeding been made or instituted against the Organization or any Lawyer or other person providing professional services on behalf of the Organization? If yes, please provide the name of the Lawyer or other person involved, the disposition of the matter, and all pertinent details (Send a separate attachment, if necessary).
0/450 characters
16. Does the organization or any person providing professional services on its behalf know of any circumstance, act, error, omission or injury 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?
0/450 characters
 
SECTION II - DATE, CALENDAR OR DOCKET CONTROL AND INTERNAL PROCEDURES
 
Since your last application for this insurance, has your organization changed, updated or modified any of its procedures
a. for maintaining calendars or dockets?
b. in addressing complaints of clients?
c. in identifying, avoiding or disclosing potential or actual conflicts of interest?
d. in notifying clients when services are completed?
e. in notifying clients or prospective clients when you decline to represent them?
 
SECTION III
1. What constitutes the management of the Organization? (Trustees, Directors' Committee, Titles of Officers, etc.) (Send separate correspondence)
 
2. How is Management selected? (Send separate correspondence)
.
 SalariedNon-Salaried
3. Number of officers and/or directors (including Executive Director)
4. Is the Organization a Not-for-Profit corporation chartered in its state of domicile?
5. Is the Organization directly in the insurance agency or brokerage business in any way?
6. Is your Organization unionized?
7. Does your organization have an internal grievance procedure to address complaints by employees?
If YES, please send a description.
 
8. Does the Organization publish any publication for limited or general distribution?
0/450 characters
9. Does the Organization sponsor any private or public meetings or conventions?
*Please identify other funding sources.  (Send separate correspondence)
 
IMPORTANT!

In the event that a claim or claims or any circumstance, act, error, omission or injury that could result in a claim against the Organization or the persons named in this application have been reported to Underwriters or disclosed on this application, or if the Organization charges fees for its services, or if the Organization does not utilize income eligibility guidelines for clients, Underwriters reserve the right to individually rate insurance for the above Organization.

It is understood that the insurance applied for will issue on the date premium is received or as agreed.  I/We hereby declare, based upon my/our knowledge and upon reasonable investigation, the above statements are true and that I/We have not suppressed or misstated any material facts and this application shall be the basis of the contract with Underwriters at Lloyd's, London.

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.

Pursuant to the provisions of the Electronic Signatures in Global and National Commerce Act (E-SIGN, 2000) execution of the application form by means of typing ones name, title and date below carries the same weight and legal effect as traditional paper documents and handwritten signatures.  Further, as a principal of Applicant, I confirm that I have authority to execute this application on behalf of Applicant.

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Please fill out the application and click the SUBMIT BUTTON at the end of the form. 
You will have a chance to save a copy for your records.