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

SECTION I
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.)
8. Does your Organization provide services other than legal (social, medical, recreational or other)?
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)?
10. Describe your Organization's practice of law by showing approximate percentages of cases involving the following:
(Total should equal 100%)
 
11. Does your Organization provide legal services to groups, corporations or associations?
13. Attorney/Staff Information    
14. Is your organization an ACLU that utilizes the services of cooperating volunteer attorneys outside of your organization?
15. Does your organization permit attorneys to engage in uncompensated outside practice of law as defined in the Legal Services Corporation regulations?
16. 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 (use a separate sheet, if necessary).

If all claims have been reported per the terms and conditions of the policy of insurance, it is not necessary for you to supply details.

17. 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?
 
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
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 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?
8. Does the Organization publish any publication for limited or general distribution?
9. Does the Organization sponsor any private or public meetings or conventions?
10. Total Annual budget (all sources) Year
 
 
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.