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RENEWAL APPLICATION FOR
LIMITED PRACTICE LAWYERS PROFESSIONAL LIABILITY AND COMERCIAL GENERAL LIABILITY INSURANCE
(THIS IS AN APPLICATION FOR CLAIMS MADE INSURANCE)

Form of Practice
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Employed
Mediator
Retired
Homemaker
2. Would you like your Limited Practice Lawyers premium quote to include coverage for Arbitration/Mediation?
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6f. Annual salary Applicant receives for this employment
7. Do you have any clerical, secretarial or other assistance in your Limited Private Practice?
8. Do your employers acknowledge your Limited Lawyers Private Practice?
9. State the number of cases handled annually in Limited Private Practice for past three years:
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10g. Please state percentage of income in Limited Private Practice derived from
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12. Describe your practice by showing the approximate amount of time involving the following. The total should equal 100%
12. Describe your practice by showing the approximate amount of time involving the following. The total should equal 100%
 % of Time
Abstracting or Title Work
Admiralty/Maritime *
Banking *
Collection/Repossession *
Communication (FCC) *
Criminal Defense/Appeals
Defendants Litigation Civil
Domestic Relations
Entertainment *
Estate Planning ***
Estate/Probate/Trust ***
Foreign Practice *
General Commercial
General Corporation
Guardian Ad Litem
International Law *
Labor Relations *
Oil & Gas **
Patents, Copyrights, TM *
Plaintiffs Litigation
Public Utilities **
Real Estate (Comm/Res)
S.E.C. Law and/or Regulations **
Taxation ***
Other:
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* NOTE: PLEASE PROVIDE FULL DETAILS OF ANY WORK PERFORMED IN THESE AREAS OF LAW.

** NOTE: ANY PRACTICE INVOLVING THESE AREAS OF LAW IS SPECIFICALLY EXCLUDED UNDER THE TERMS OF THE POLICY OF INSURANCE.

*** If your type of work includes Estate Planning, Estate/Probate/Trust or Taxation, then please complete the Supplemental Tax Questionnaire.
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* NOTE:  PLEASE PROVIDE FULL DETAILS OF ANY WORK PERFORMED IN THESE AREAS OF LAW.

** NOTE:  ANY  PRACTICE  INVOLVING  THESE  AREAS OF LAW IS SPECIFICALLY EXCLUDED UNDER THE TERMS OF THE POLICY OF INSURANCE.

*** If your type of work includes Estate Planning, Estate/Probate/Trust or Taxation, then please complete the Supplemental Tax Questionnaire.
14a. In your Limited Private Practice, do you ever accept matters which may require your appearance in court?
14b. If “yes”, can you guarantee your employer will allow you the necessary time off to do so?
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15. Please give full particulars of all similar insurances carried during the past five years:
 InsurerPolicy No.Limits of LiabilityDeductiblePeriodClaims made or Occurrence
.
.
.
.
.
17. Has any similar insurance for the Applicant ever been declined or cancelled?
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18. Have you ever been reprimanded by, refused admission to practice, disbarred or suspended from practice before any court or administrative agency ?
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19. Have any Professional Liability \ General Liability claims or suits been made during the past five years against the Applicant or is the Applicant aware of any circumstance, act, error, omission or injury or occurrence that could result in any claim being made against the Applicant
15. Do you act in a Fiduciary Capacity as a trustee for a trust, executor for a will or similar capacity?
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20. Has the Applicant given written notice under the provisions of any prior or current cyber risk, media or network security policy of specific facts or circumstances which may give or have given rise to a Claim being made against any proposed Insured, or do they know of specific facts or circumstances which may give or have given rise to a Claim?
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22. Please explain what the Applicant has done to reduce the number of fee related disputes with Clients:
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22b. Please check appropriate box(es) for limits of liability you require for each claim. *
 
22c. What deductible are you prepared to carry? *
23. Do you comply with all applicable regulatory and industry supported privacy and security standards and frameworks that are applicable to your industry, including PCI data to your business?
24. Does applicant use intrusion detection software, firewall protection and anti-virus systems to detect/prevent unauthorized access to internal networks and computer systems?
25. Does applicant have a written procedure to communicate a privacy breach to state authorities and affected parties?
31. Would you like your Limited Practice Lawyers premium quote to include coverage for Arbitration/Mediation?
NOTICE TO APPLICANT:

I/We declare that the information contained herein is true and that it shall be the basis of the
insurance and deemed incorporated therein, should the Underwriters evidence its acceptance of
this application by issuance of coverage. 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, the
Applicant 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
Underwriters, then no coverage for such claim is afforded the Applicant under the insurance.
 
IMPORTANT: Underwriters reserve the right to individually rate insurance for the above
Applicant based upon the Applicant's experience.
 
I understand and accept that the insurance applied
for provides coverage on a CLAIMS MADE basis for ONLY THOSE CLAIMS MADE
AGAINST THE INSURED WHILE THE INSURANCE IS IN FORCE and that coverage ceases with the
termination of the insurance unless I exercise options available and in accordance with terms of
the policy.
 
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
effect as traditional paper documents and handwritten signatures. onfirm that I have authority to
execute this application on behalf of Applicant.
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*  SIGNING THIS FORM AND TENDERING PREMIUM DOES NOT BIND THE APPLICANT OR THE UNDERWRITERS TO  COMPLETE  THE  INSURANCE.    Application MUST be SIGNED and DATED to be considered for quotation.

 
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.