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.

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."

* 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.

Cyber Liability Section – OPTIONAL

General Liability Section – OPTIONAL

Please indicate Limits of Liability for quotation.

NOTICE TO APPLICANT:

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.

**  SIGNING  THIS  FORM  AND  TENDERING  PREMIUM DOES NOT BIND THE APPLICANT OR THE UNDERWRITERS TO COMPLETE THE INSURANCE.  Application MUST be SIGNED to be considered for quotation.

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.