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LAWYERS PROFESSIONAL LIABILITY INSURANCE
NATIONAL DISABILITY RIGHTS NETWORK, INC.
(This policy does not cover Private Law Practice)
This is an application for a Claims Made Policy.
SECTION I
-- Coverage A-1
LAWYERS PROFESSIONAL LIABILITY COVERAGE
(including Notary Public Professional Liability)
PERSONAL INJURY LIABILITY
SOCIAL ENGINEERING FRAUD LIABILITY
DISCIPLINARY PROCEEDINGS COSTS
1. Name of Organization
*
Address
*
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
*
County
Area Code/Phone
Area Code/Fax
Email Address
Website Address
Mailing Address
Date Organization established
+
2. List Branch Offices and Addresses, if any:
A.
B.
C.
3. Type of Organization (Describe the purpose, general operations and functions of your Organization. (Send separate attachment if necessary.)
4. How is your Organization funded?
Indicate percentages of such funding (the total should equal 100%):
5. Total number of cases and/or files handled or processed annually (excluding Rep Payee Reviews):
Total number of Representative Payee Review Cases processed annually (Estimates may be used if exact counts are unavailable):
6. Does the Organization accept cases for clients who are not indigent and whose incomes are above the national poverty level? (Please send a copy of guidelines for client eligibility.)
Yes
No
7. If fees for services have been established by your Organization, please specify the type of case and the maximum fee charge presently used for each type of case (excluding registration fees and court costs). If no fees are charged, insert "Not Applicable". (Please also send a copy of your written protocol for the transfer of funds by electronic means as this is a requirement for coverage to apply.)
8. Does your Organization provide services other than legal (i.e. social, medical, recreational, or other)? If YES, please send written explanation.
Yes
No
9. Does your Organization operate a pro bono or judicare program whereby your Organization utilizes the services of attorneys outside of your Organization?
Yes
No
Please describe program (screening procedures, types of cases referred, referral procedure and follow up or monitoring procedure).
Please also provide: a) Maximum number of pro bono/judicare panel attorneys
b) Maximum number of pro bono/judicare cases referred annually.
10. Understanding that:
Paid
means both salaried and hourly employees.
Full-time
means an employee working 30 or more hours per week.
Part-time
means an employee working less than 30 hours per week.
Attorney/Lawyer
means any employee who is allowed to practice law in any U.S. State or Territory or Canada or any of its Territories regardless of whether or not the employee represents clients for and on behalf of the Organization.
Non-Attorney Professionals
means employees (excluding strictly clerical employees and attorneys) working in any of the following capacities: non-attorney executive director, paraprofessional, advocate, representative payee reviewer, legal secretary, law student, intern, social worker, intake & referral, notary public, outreach, publications that are made available to the public including website and social media content, legal research and/or advocacy research, personnel who oversee any attorney or non-attorney professionals, and personnel performing duties in any like manner to any of the above named capacities.
Strictly Clerical
means an employee with minimal or zero client contact that does not fit into any of the above categories and who is overseen by an Assured employee.
All employees other than
Strictly Clerical
employees must be listed for coverage in one of the two following charts (send a separate sheet if necessary).
Lawyers Name
Full-Time/Part-Time Status
Paid/Volunteer Status
Rep Payee Reviewer (check if Yes)
Percent of time spent performing Rep Payee Reviews
.
Lawyers Name
Full-Time/Part-Time Status
Paid/Volunteer Status
Rep Payee Reviewer (check if Yes)
Percent of time spent performing Rep Payee Reviews
.
Lawyers Name
Full-Time/Part-Time Status
Paid/Volunteer Status
Rep Payee Reviewer (check if Yes)
Percent of time spent performing Rep Payee Reviews
.
Lawyers Name
Full-Time/Part-Time Status
Paid/Volunteer Status
Rep Payee Reviewer (check if Yes)
Percent of time spent performing Rep Payee Reviews
.
Lawyers Name
Full-Time/Part-Time Status
Paid/Volunteer Status
Rep Payee Reviewer (check if Yes)
Percent of time spent performing Rep Payee Reviews
.
Lawyers Name
Full-Time/Part-Time Status
Paid/Volunteer Status
Rep Payee Reviewer (check if Yes)
Percent of time spent performing Rep Payee Reviews
10b)
Non-Attorney Professionals Name
Full-Time/Part-Time
Paid/Volunteer
Rep Payee Reviewer (check if Yes)
Percent of time spent performing Rep Payee Reviews
1
Non-Attorney Professionals Name
Full-Time/Part-Time
Paid/Volunteer
Rep Payee Reviewer (check if Yes)
Percent of time spent performing Rep Payee Reviews
2
Non-Attorney Professionals Name
Full-Time/Part-Time
Paid/Volunteer
Rep Payee Reviewer (check if Yes)
Percent of time spent performing Rep Payee Reviews
3
Non-Attorney Professionals Name
Full-Time/Part-Time
Paid/Volunteer
Rep Payee Reviewer (check if Yes)
Percent of time spent performing Rep Payee Reviews
4
Non-Attorney Professionals Name
Full-Time/Part-Time
Paid/Volunteer
Rep Payee Reviewer (check if Yes)
Percent of time spent performing Rep Payee Reviews
5
Non-Attorney Professionals Name
Full-Time/Part-Time
Paid/Volunteer
Rep Payee Reviewer (check if Yes)
Percent of time spent performing Rep Payee Reviews
6
Non-Attorney Professionals Name
Full-Time/Part-Time
Paid/Volunteer
Rep Payee Reviewer (check if Yes)
Percent of time spent performing Rep Payee Reviews
7
Non-Attorney Professionals Name
Full-Time/Part-Time
Paid/Volunteer
Rep Payee Reviewer (check if Yes)
Percent of time spent performing Rep Payee Reviews
11. Do you have any vacant positions (excluding
Strictly Clerical
positions)?
Yes
No
If Yes, please indicate the following: (send a separate sheet if necessary).
Position and Expected Fill-By Date
Full-Time/Part-Time
Paid/Volunteer
Rep Payee Reviewer (check if Yes)
Percent of time spent performing Rep Payee Reviews
.
Position and Expected Fill-By Date
Full-Time/Part-Time
Paid/Volunteer
Rep Payee Reviewer (check if Yes)
Percent of time spent performing Rep Payee Reviews
.
Position and Expected Fill-By Date
Full-Time/Part-Time
Paid/Volunteer
Rep Payee Reviewer (check if Yes)
Percent of time spent performing Rep Payee Reviews
12. Are any staff included in answer to Question 10, Social Workers?
Yes
No
If Yes, please provide:
a) Social Workers Name(s):
b. Number of Social Work Interns/Law Students expected per semester (please provide name(s) if known):
13. Does your Organization utilize Outside Contractors, Consultants or Co-Counsels for Attorney or Non-Attorney Professional type work?
Yes
No
If YES, please provide each person’s name, position, start date/end date (if known), else use an estimated end date or list as ongoing, number of hours per week working for and on behalf of your Organization, and a brief description of the work the Outside Contractor, Consultant and/or Co-Counsel is performing for and on behalf of your Organization. (send a separate sheet if necessary)
0/200 characters
14. Please describe the activities of your Organization by showing approximate time spent involving the following: (Total should equal 100%. Please use Whole Numbers)
🛈
A. Investigation of incidents of abuse and neglect
B. Pursuit of Administrative remedies
C. Pursuit of Legal (Litigation) remedies
D. Pursuit of Other remedies
E. Negotiation and Mediation of problems
F. Providing Technical Assistance to attorneys, government agencies and service providers
G. Training advocates, consumers, volunteers, professionals and other parties
0/100 points
15. Describe your Organization's practice of law by showing approximate percentages of cases involving the following: (Total should equal 100% Please use Whole Numbers)
🛈
Advocacy for Developmentally and/or Mentally Disabled Persons
Bankruptcy
Bodily/Personal Injury
Child/Spouse Abuse
Corporate
Criminal
Defendant
Divorce/Family Law
Farm Aid
Guardianships
Housing Law
Juvenile
Landlord/Tenant
Plaintiff
Public Benefits Law (Social Sec., Unemployment Comp., Workmen's Comp., Medicare)
Real Estate
Wills/Estate Work
Other (describe below)
0/100 points
Other - Please specify
16. Has any claim, suit, charge, investigation or proceeding
ever
been made or instituted against the Organization or any Lawyer or other person providing professional services on behalf of the Organization which alleges any of the following types of conduct?
(a) Negligent acts or omissions in the course of rendering professional services as a Lawyer under the direction of a Lawyer or Notary Public?
Yes
No
(b) Attorney misconduct or breach of professional ethics?
Yes
No
(c) False arrest, detention or imprisonment or malicious prosecution?
Yes
No
(d) Publication or utterance of a libel or slander or of any other defamatory or disparaging material or publication or utterance in violation of an individual's right of privacy?
Yes
No
(e) Wrongful entry or eviction, or other invasion of the right of private occupancy?
Yes
No
(f) Conduct for which the claimant seeks an award of punitive or exemplary damages?
Yes
No
(g) Violation of a federal, state, municipal or local criminal statute or law?
Yes
No
(h) Conduct which may give rise to a contempt proceeding?
Yes
No
(i) Any conduct in connection with the employment, hiring, failure to hire, discharge or termination of the employment of an employee, former employee or applicant for employment?
Yes
No
(j) Conduct of Directors/Officers and/or other management personnel alleging negligence in their official capacity as management?
Yes
No
If any of the above items in 16 are answered YES, please provide the name of the Lawyer or other person involved, the disposition of the matter, and all other pertinent details (send a separate attachment if necessary).
0/255 characters
17. Does the Organization or any person specified in response to Questions 10 and 13 know of any circumstance, act, error, omission or inquiry that could result in a claim, suit, charge, investigation or proceeding against the Organization or any Lawyer or other person providing the professional services on behalf of the Organization based on any of the types of conduct described in Question 16 above?
Yes
No
If YES, please provide the name of the Lawyer or other person involved and all other pertinent details (send a separate attachment if necessary).
0/255 characters
18. Does your Organization provide legal services to groups, corporations or associations?
Yes
No
If YES, please provide detailed description (types of groups/corporations/associations, specific legal services provided, etc.) (Send additional attachment if necessary).
0/255 characters
19. If you have answered YES to Question 18 above, please indicate whether the group, corporation or association is primarily composed of persons eligible for legal aid services and whether such group, corporation or association has provided information showing it lacks and has no practical means of obtaining funds to retain private counsel.
0/255 characters
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.