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LAWYERS PROFESSIONAL LIABILITY INSURANCE

Issued to The

NATIONAL DISTRICT ATTORNEYS ASSOCIATION

And

SPECIFIED MEMBER ORGANIZATIONS

 (This policy does not cover Private Law Practice)

THIS IS AN APPLICATION FOR A CLAIMS MADE POLICY

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 List Branch Offices and Addresses, if any
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 List names of all lawyers (full or part-time) providing professional services on behalf of the Organization:*List names of all practicing Law Students, Legal Interns and Paralegals providing professional services on behalf of the Organization:List names of all Investigators providing professional services on behalf of the Organization:
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Other paid personnel employed by the Prosecuting Attorney's office such as secretaries, file clerks and receptionists are covered according to the conditions of this policy.
 
 
5. 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? (Please check appropriate box.)
(a) Negligent acts or omissions in the course of rendering professional services as a Lawyer or Notary Public?
(b) Attorney misconduct or breach of professional ethics?
(c) False arrest, detention or imprisonment or malicious prosecution?
(d) 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?
(e) Wrongful entry or eviction, or other invasion of the right of private occupancy.
(f) Conduct for which the claimant seeks an award of punitive or exemplary damages?
(g) Violation of a federal, state, municipal or local criminal statute or law?
(h) Conduct which may give rise to a contempt proceeding?
(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?
(j) Conduct which has resulted in an injunction or functionally similar order, including but not limited to a restraining order, a writ of mandamus, a writ of prohibition or an order to compel prosecution?
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6. Does the Organization or any person specified in response to Question 4 know of any circumstance, act, error, omission or injury that could result in a claim, suit, charge, investigation or proceeding against the Organization or any Lawyer or other person providing professional services on behalf of the Organization based on any of the types of conduct described in Question 5 above?
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IMPORTANT

In the event that a claim or claims against the Organization or the Lawyers named in this application have been reported to Underwriters or disclosed in this application, Underwriters reserve the right to individually rate insurance for the above applicant based upon the applicant's experience.

 

It is understood that the policy applied for will issue on the 1st day of the month following receipt of the premium and the acceptance of the application by the insurer. I/We hereby declare, based upon my/our knowledge and upon reasonable investigation, that the above statements are true and that I/we have not suppressed or misstated any material facts and that this Proposal Form shall be the basis of the contract with the Underwriters at Lloyd's, London.

 

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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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.