Save & Return

Use an account to return to saved work.

(Specified Member Firms of Arizona Attorneys For Criminal Justice)
(Application for "Claims Made" Policy)

Applicant's Instructions:

ANSWER ALL QUESTIONS.  If the answer to any question is None or Not Applicable, Please state "NO".  If space is insufficient to answer any questions fully, use a separate attachment.
Application must be SIGNED and DATED by owner, partner or officer.

2. Type of Business:
3. Has the type of business changed in the last 5 years?
4. Has the name of Firm been changed during the past five years?
0/230 characters
0/450 characters
0/450 characters
11. If Applicant is sole practitioner, state:
(a) Whether you are engaged in independent private practice?
11. (b) Does the applicant provide professional services as an attorney on behalf of any other attorney or firm?  
0/230 characters
0/350 characters
12. Does any lawyer named in Questions 6, 7 & 8 have any other law partner, associate, or employed lawyer other than those in Questions 6, 7 & 8?
0/350 characters
13. Does any lawyer named in Questions 6, 7 & 8 share office space with any lawyer NOT NAMED in Questions 6, 7 & 8?
0/350 characters

14. Describe your practice by first showing approximate amount of time devoted to the following:

(c) Total Areas of Practice (a+b)       = 100%
Describe "OTHER" below by showing percentages of time devoted to the following: (Your answer should equal the percentage shown above in 14. b)
0/120 characters

** If your type of work includes Estate Planning, Estate/Probate/Trust or Taxation, then please complete the Supplemental Tax Questionnaire.

16. Is the applicant currently insured under a Claims Made professional liability policy?

18. Please give full particulars of all similar insurances carried during the past five years:

0/450 characters
19. Has any professional liability insurance for the applicant, present Partner or predecessors or any lawyer in the firm ever been declined or cancelled, refused to be renewed?
0/450 characters
20. After inquiry of each lawyer in the firm, has any lawyer in the firm ever been reprimanded by, or refused admission to practice, disbarred, or suspended from practice before any court or administrative agency or been subject to disciplinary complaints or actions?
0/450 characters
21. After inquiry of each lawyer in the firm, have any claims or suits ever been made against any lawyer in the firm, or their predecessors in business?
0/450 characters
22. After inquiry of each lawyer in the firm, does any lawyer in the firm know of any circumstances, act, error, omission or personal injury that could result in any claim being made against him/her or, their (his/her) predecessors in business or any of the present or past partners?
0/450 characters
0/450 characters
24. Applicants approximate gross billable dollars for the past 12 months are:
25. Does Applicant's practice also involve acting in the capacity of any of the following?

If yes, indicate the percent of practice devoted to each and whether separate professional liability insurance is carried for this work:

26. Is the applicant or any Partner or Lawyer of the Firm a salaried employee, partner, officer, director or owner of any organization other than the Firm?
0/230 characters

27. Please provide the following information:


Retroactive Date:  You may request the same Retroactive Date that is on your present policy if you have had continuous "claims made" coverage since that date.  If you are not currently covered by a "claims made" Lawyers Professional Liability Insurance Policy, then your Retroactive Date will be at Inception, which means no prior acts coverage will be afforded for any acts, errors or omissions committed, in whole or in part, prior to the Inception Date of any policy issued by Underwriters.

28. Are you a member of the Arizona Attorneys for Criminal Justice?

WARRANT:  I/We warrant that the information contained herein is true and that it shall be the basis of the policy of insurance and deemed incorporated therein, should the Underwriters evidence their acceptance of this application by issuance of a policy.  I/We hereby authorize the release of claim information from any prior insurer to Underwriters.
NOTE:  In applying for coverage, the applicant agrees that in the event of covered losses, he will be required to be defended by the Underwriters' appointed lawyers, and that the deductible shall apply to loss and claim expenses, adjusting expenses, investigation costs, and legal fees.  If the applicant elects to handle a claim without in any way involving the Underwriter, then no coverage for such claim is afforded the applicant under the policy.

I understand and accept that the policy applied for provides coverage on a CLAIMS MADE basis for ONLY THOSE CLAIMS FIRST MADE AGAINST THE INSURED WHILE THE POLICY IS IN FORCE and that coverage ceases with the termination of policy unless I exercise options available and in accordance with terms of the policy.