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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, attach a separate sheet. Application must be SIGNED and DATED by owner, partner or officer.

Note: All information disclosed on this application, together with any supplementary information regarding the applicant is considered to be privileged information, and will be held in strict confidence with the exception that it must be made available to Underwriters. It will not be released unless your written consent is given.
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?
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11. If Applicant is sole practitioner, state: (a) Whether you are engaged in independent private practice
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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?
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13. Does any lawyer named in Questions 6, 7 & 8 share office space with any lawyer NOT NAMED in Questions 6, 7 & 8?
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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)

*If adoption matters are dealt with, please give full details on a separate page.
** If your type of work includes Estate Planning, Estate/Probate/Trust, or Taxation, then please complete the Supplemental Tax Questionnaire.

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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:
 InsurerPremiumLimits of LiabilityDeductiblePeriodClaims Made or Occurrence Form
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?
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20. DOCKET CONTROL - (Calendars, Tickler Systems, etc.)  In a separate correspondence, please provide details of system, including explanation of date controls used in your office and who has responsibility for entry of items assigned.
21. Applicants approximate gross billable dollars for the past 12 months are:
22. Does Applicant's practice also involve acting in the capacity of any of the following?
If so, indicate the percent of practice devoted to each and whether separate professional liability insurance is carried for this work:
23. Was 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? (If so, please provide details including any interests held in a separate correspondence)
24. Does (or did) the Applicant or any lawyer named in answer to Questions 6, 7 and 8 of the application ever provide legal services on behalf of clients with respect to Investment visas?
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An Investment Visa is defined as: "A visa for alien entrepreneur which involves the investment of the alien's money in a business or business entity, including but not limited to a corporation, partnership, joint venture or sole proprietorship pursuant to Section 203(b)(5) of the Immigration and Naturalization Act, also codified at 8 U.S.C. 1153(b)(5), or which involves the investment of the alien's money in any other visa program which involves creation of employment in the United States."

25. Please provide the following information:    INSURANCE REQUESTED
(e) Enclose a sample of your retainer/agreement letter and letterhead

* 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 insured by a "claims made" Lawyers Professional Liability Insurance Policy, then your Retroactive Date will be at Inception, which means no 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.

26. 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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27. 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 stemming from the types of conduct listed above?
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Cyber Liability Section – OPTIONAL

1. 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?
2. Does applicant use intrusion detection software, firewall protection and anti-virus systems to detect/prevent unauthorized access to internal networks and computer systems?
3. Does applicant have a written procedure to communicate a privacy breach to state authorities and affected parties?
4. 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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General Liability Section – OPTIONAL

1. Have any 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?
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Please indicate Limits of Liability for quotation.

Professional Liability
General Liability:
The Limits chosen for General Liability must be at or lower than the Limits chosen for Professional Liability
Cyber Liability:
The Limits chosen for Cyber must be at or lower than the Limits chosen for Professional Liability.
Deductible Requested for Professional Liability


I/We hereby declare 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.  All information disclosed on this application, together with any supplementary information obtained regarding the applicant remains the exclusive property of CEM.

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 FIRST MADE basis for ONLY THOSE CLAIMS FIRST MADE AGAINST THE ASSURED 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.

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.




This Proposal Form duly completed, together with any supplementary information, must be signed by the applicant or a partner of the Firm.  One signed copy will be attached to and form part of the Policy or Certificate, if issued.  Completion of this Proposal Form does not bind or obligate the Firm or the Underwriters to complete the insurance.

Please fill out form and click the SUBMIT BUTTON at the bottom of the form. 
You will have a chance to save a copy for your records.