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

Save & Return

Use an account to return to saved work.

Application for
LAWYERS PROFESSIONAL LIABILITY INSURANCE
Issued to
National Association of Salaried Professional Purchasing Group, Inc.
and
Specified Member Organizations
Public Defender/Assigned Counsel Application
(This policy does not cover Private Law Practice)
This is an application for Claims Made Insurance

SECTION I

LAWYERS PROFESSIONAL LIABILITY COVERAGE (Including Notary Public Professional Liability)

Application to participate in the Lawyers Professional Liability Insurance Coverage:
0/255 characters
5. Has any professional liability claim or suit ever been made against the Organization or Lawyers listed in response to question 9?
0/255 characters
6. Does the Organization or any Lawyer listed in response to question 9 know of any circumstance, act, error, omission or personal injury that could result in a professional liability claim against him/her or the Organization named in the application?
0/255 characters
7. Has any Notary Public errors and omissions claim ever been made against the Organization, any individual listed as a Lawyer/Law Student/Paraprofessional under question 9 or against any other individual providing services on behalf of the Organization?
0/255 characters
8. Does the Organization or any individual providing services on behalf of the Organization, know of any circumstance, act, error, omission or personal injury that could result in a Notary Public errors and omissions claim against him/her or the Organization?
0/255 characters
9. List ALL Lawyers (including part-time salaried and volunteer lawyers), law students, paralegals and investigators including those projected for policy period. Use the word "VACANT" in columns 1 and 2 for projected employment of lawyers and law students/paraprofessional/investigators. New employees will be covered at no additional cost, but reduction of personnel will not result in return of pro-rata premium during the policy year. When a large turnover in personnel occurs, you may approximate the number of Lawyers and/or Law Students by using the highest number employed at any one time during the year.
 Lawyers?
1
2
3
4
5
6
 Law Students/Paralegals/Investigators? *
1
2
3
4
5
6
*Indicate if part-time (PT) or volunteer (V)
Does your organization use the services of attorneys, paralegals or investigators outside of your organization on an appointment or contract basis
If YES, please respond to the questions below:
G. Describe your procedure for monitoring and removing attorneys, paralegals or investigators (send separate documentation)

10. Describe your Organization's practice of law by showing the approximate percentage of cases involving criminal matters:

If your practice of law includes civil matters*, please indicate the approximate percentage of cases involving the following:

(Total of all of the above should equal 100%)
*Underwriters reserve the right to individually rate insurance for the Organization
if the Organizations's practice includes civil matters.


SECTION II
MANAGEMENT ERRORS & OMISSIONS COVERAGE and EMPLOYMENT PRACTICES COVERAGE
3. Is the Organization a Not-For-Profit corporation, chartered in the state of domicile?
0/255 characters
4. Is the Organization directly in the insurance agency or brokerage business in any way?
0/255 characters
0/255 characters
6. Does the Organization sponsor any private or public meetings or conventions?
7. During the past 10 years has there ever been a liability claim made against the Organization or its management personnel?
0/255 characters
8. Is the Organization aware of any circumstance, act, error, omission or personal injury that could result in a liability claim against the Organization or any of its past or present directors, officers, or employees?
0/255 characters
9. Has any claim or suit or charge before any government agency concerning the employment practices of the Organization been made against the Organization or any of its past or present directors, officers, or employees by an employee, former employee or prospective employee?
0/255 characters
10. Is the Organization aware of any circumstance, act, error, omission or personal injury that could result in a claim, suit or charge before any government agency being made against the Organization or any of its past or present directors, officers, or employees by an employee or prospective employee concerning the employment practices of the Organization?
0/355 characters
SECTION III
DISCIPLINARY PROCEEDINGS COSTS COVERAGE
(This section MUST be completed to obtain the basic Professional Liablility quotation)
1. Has any Disciplinary Proceedings (attorney misconduct) claim ever been made against the Organization, any individual listed as a Lawyer/Law Student/paraprofessional on the Lawyers Professional Liability Insurance application or against any other individual providing services on behalf of the Organization?
0/355 characters
2. Does the Organization or any individual providing services on behalf of the Organization know of any circumstance, act, error, omission or personal injury that could result in a Disciplinary Proceedings (attorney misconduct) claim against him/her or the Organization?
0/355 characters
SECTION IV
CRIMIAL DEFENSE COVERAGE
(This section MUST be completed to obtain the basic Professional Liablility quotation)
1. Has any claim, suit, charge, investigation or proceeding ever been made or instituted against the Organization, its Management, or any Lawyer or other person providing professional services on behalf of the Organization which alleged violation of a federal, state, municipal or local criminal statute or law?
0/355 characters
2. Does the Organization, its Management, or any person specified in response to Section I, Question 9 of the application know of any circumstance, act, error, omission or injury that could result in a claim, suit, charge, investigation or proceeding against the Organization, its Management or any Lawyer or other person providing professional services on behalf of the Organization based on an alleged violation of a federal, state, municipal or local criminal statute of law?
0/355 characters
SECTION V
CONTEMPT DEFENSE COVERAGE
(This section MUST be completed to obtain the basic Professional Liablility quotation)
1. Has the Organization or its Management, or any Lawyer or other person providing professional services on behalf of the Organization, ever been the subject of criminal or civil contempt proceedings, or cited for criminal or civil contempt, by any court, administrative agency or governmental body?
0/355 characters
2. Does the Organization, or its management officials, or any Lawyer or other person providing professional services on behalf of the Organization, know of any incident, circumstance, act, error or omission that could result in the initiation of criminal or civil contempt proceedings, or the imposition of a contempt citation, against the Organization, or any such management official, Lawyer or other person?
0/355 characters

In the event that a claim or claims or any circumstance, act, error, omission or personal injury that could result in a claim against the Organization or the persons named in the application have been reported to Underwriters or disclosed on the application, or if the Organization's practice includes civil matters, Underwriters reserve the right to individually rate insruance for the above Organization.

 

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.

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