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APPLICATION FOR
LIMITED PRACTICE LAWYERS PROFESSIONAL INDEMNITY INSURANCE
(THIS IS AN APPLICATION FOR CLAIMS MADE INSURANCE)

NOTICE TO APPLICANT:

(1)    It is a requirement of this insurance that the Applicant has either a full-time employer(s), and/or a mediation/arbitration practice, and/or is retired, and/or is a homemaker. If you do not  meet one of these requirements in some capacity other than your own private practice, then this insurance is not applicable.
(2)    There is no coverage whatsoever for any legal work performed by the Assured for his/her employer(s).

APPLICANT'S INSTRUCTIONS:

(1)    ANSWER ALL QUESTIONS. If the answer to any question is None or Not Applicable, please state "NONE" or "NOT APPLICABLE".
(2)    If space is insufficient to answer any questions fully, attach a separate sheet/email.
(3)    Application must be SIGNED and DATED by the Named Applicant.
(4)    PLEASE READ CAREFULLY THE STATEMENTS AT THE END OF THIS APPLICATION.
Form of Practice
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2 a) Employed
Mediator
Retired
Homemaker
g) Annual salary Applicant receives for this employment
4. Do you have any clerical, secretarial or other assistance in your Limited Private Practice?
5. Do your employers acknowledge your Limited Lawyers Private Practice?
6. State the number of cases handled annually in Limited Private Practice for past three years:
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8. Please state percentage of income in Limited Private Practice derived from
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11. Describe your practice by showing the approximate amount of time involving the following. The total should equal 100%
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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.
12. a) In your Limited Private Practice, do you ever accept matters which may require your appearance in court?
12. b) If “yes”, can you guarantee your employer will allow you the necessary time off to do so?
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13. Do you act in a Fiduciary Capacity as a trustee for a trust, executor for a will or similar capacity?
14. Please give full particulars of all similar insurances carried during the past five years:
 InsurerPolicy No.Limits of LiabilityDeductiblePeriodClaims made or Occurrence
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15. Has any similar insurance for the Applicant ever been declined or cancelled?
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16. 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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17. Have any claims or suits been made during the past five years against the Applicant either as an individual or as an employed Lawyer or Partner of any other firm?
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18. Is the Applicant aware of any circumstance, act, error, omission or injury that could result in any claim being made against the Applicant?
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20. Please explain what the Applicant has done to reduce the number of fee related disputes with Clients:
 
22. Has any claim alleging negligent acts or omissions in the course of rendering professional services as a Notary Public ever been made against the Applicant?
0/260 characters
23. Is the Applicant aware of any circumstance, act, error, omission or injury that could result in a claim against the Applicant alleging negligent acts or omissions in the course of rendering professional services as a Notary Public?
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24. Has any claim been brought against the Applicant which alleges any of the following types of conduct:
a) False arrest, detention or imprisonment or malicious prosecution?
b) Publication or utterance of a libel or slander or of other defamatory or disparaging material or publication or utterance in violation of an individual's right of privacy?
c) Wrongful entry or eviction, or other invasion of the right of private occupancy?
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25. Is the Applicant aware of any circumstance, act, error, omission or injury that could result in a claim against the Applicant based on any of the types of conduct described in Question 24?
0/260 characters
26. Has any Disciplinary Proceedings ever been instituted against the Applicant by any court, bar association, or committee or board thereof, or commission established by constitutional provision, statute, or court rule to investigate, review or impose disciplinary sanctions for charges of attorney misconduct?
0/260 characters
27. Is the Applicant aware of any circumstance, act, error, omission or injury that could result in a Disciplinary Proceeding being instituted against the Applicant by any court, bar association, or committee or board thereof, or commission established by constitutional provision, statute or court rule to investigate, review or impose disciplinary sanctions for charges of attorney misconduct?
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31. Would you like your Limited Practice Lawyers premium quote to include coverage for Arbitration/Mediation?

NOTICE TO APPLICANT:

WARRANTY:      I/We warrant 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 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.

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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.