Limited Practice Renewal App

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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)

Name of Applicant (Mr. Ms. Dr.): *

Physical Address *

City *

State *

Zip *

Email Address

Area Code/Phone No.

Fax No.

Mailing Address

2 a) Employed

Yes

No

Mediator

Yes

No

Retired

Yes

No

Homemaker

Yes

No

b) Name of Employer or Mediation Practice

c) Address of Employer

d) Nature of Employer's Business

e) Nature of Applicant's Employment

f) Number of hours per week Applicant is so employed

g) Annual salary Applicant receives for this employment

0 - $20,000

$20,001 - $40,000

$40,001 - $60,000

Over $60,000

3. Would you like your Limited Practice Lawyers premium quote to include coverage for Arbitration/Mediation?

Yes

No

4. Total number of Mediation cases you expect to handle in the next 12 months

5. State GROSS INCOME derived from your Mediation Practice over the past 12 months

6. Do you have any clerical, secretarial or other assistance in your Limited Private Practice?

Yes

No

If “yes”, describe

7 a) Total number of Litigation cases you expect to handle in the next 12 months

b) Total number of Non-Litigation cases you expect to handle in the next 12 months

c) How many of the cases that you are currently handling do you expect to require more than 12 months to resolve?

Please provide details of these cases (i.e., type of case, estimated settlement date, estimated fees to be derived from each case, etc

0/255 characters

d) State GROSS INCOME derived from your Lawyers Limited Private Practice over the past 12 months

e) State the approximate number of hours per week devoted to your Limited Private Practice

8. a) Do you require a different Limit or Deductible from your expiring policy?

Yes

No

b) If so, please give details

0/200 characters

9. Is the Applicant aware of any circumstance, act, error, omission or injury that could result in any claim being made against the Applicant?

Yes

No

If “yes”, please give full particulars, send a separate correspondence if needed

0/260 characters

10. Describe your practice by showing the approximate amount of time involving the following. The total should equal 100%

	Abstracting or Title Work
	Admiralty/Maritime *
	Banking *
	Collection/Repossession *
	Communication (FCC) *
	Criminal Defense/Appeals
	Defendants Litigation Civil
	Domestic Relations
	Arbitration/Mediation
	Entertainment *
	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 (please specify and describe fully)

0/100 points

* 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.

11. 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?

Yes

No

12. Does applicant use intrusion detection software to detect unauthorized access to internal networks and computer systems?

Yes

No

13. Does applicant use firewall protection and anti-virus systems to prevent unauthorized access to internal networks and computer systems?

Yes

No

14. Does applicant have a written procedure to communicate a privacy breach to state authorities and affected parties

Yes

No

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 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.

Named Applicant

/s/ Electronic Signature *

Date Signed * +

* 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.