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Broker Name Evanston Insurance Company Broker Street Markel (Risk Placement Services, Inc.)

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MALP 0001 02 17 Page 1 of 10
LAWYER’S ERRORS & OMISSIONS LIABILITY INSURANCE APPLICATION
THIS IS AN APPLICATION FOR CLAIMS-MADE AND REPORTED INSURANCE. THIS COVERAGE IS LIMITED TO CLAIMS FIRST MADE AND
REPORTED TO THE COMPANY DURING THE POLICY PERIOD AS STATED IN THE DECLARATIONS OR ANY APPLICABLE EXTENDED
REPORTING PERIOD. IT IS IMPORTANT THAT YOU REPORT ANY CURRENTLY KNOWN CLAIMS OR CIRCUMSTANCES THAT COULD
RESULT IN A CLAIM TO YOUR CURRENT INSURER OR PURCHASE AN EXTENDED REPORTING PERIOD ENDORSEMENT TO COVER SUCH
CLAIMS OR INCIDENTS. THE INSURER WILL NOT PROVIDE COVERAGE FOR CLAIMS OR INCIDENTS WHICH YOU ARE AWARE OF PRIOR
TO THE INCEPTION DATE OF THIS COVERAGE, IF OFFERED AND ACCEPTED.
INSTRUCTIONS FOR COMPLETING APPLICATION:
Enclose a copy of the Applicant's letterhead.
Please type or print clearly in ink. All questions must be answered
completely. If any questions are considered “not applicable,” please explain why. If you need more space, continue on a
separate sheet and indicate the question number. This application and all supplemental forms must be signed and dated
by a principal of the Applicant.
Proposed Effective Date: From To
12:01 a.m. Standard Time at the address of the Applicant
I. GENERAL INFORMATION
1. Applicant:
2. Street Address: City:
County:
St:
Zip:
Do you have additional office locations? If Yes, please provide details on a separate attachment.
3. a. Telephone Number: b. Fax Number:
c. Website Address:
4. Date the Applicant was established:
5. List all Predecessors in Business:
”Predecessor in Business” means any law firm which has undergone dissolution and to which
any of the
following apply:
a. some or all of such firms, principals, owners, officers or partners have joined the Named Insured, provided such
persons were responsible for producing in excess of 50% of the prior firm's annual gross revenues and such
billings have been assigned or transferred to the Named Insured; or
b. at least 50% of the principals, owners, partners or officers of the prior firm have joined the Named Insured; or
c. the Insured has assumed 50% or greater of the prior firm’s assets and liabilities.
NAME OF FIRM
DATE
FORMED
DATE OF
MERGER OR
DISSOLUTION
IF APPLICABLE
PERCENTAGE
OF ASSETS AND
LIABILITIES
ASSUMED
NO. OF
PRINCIPALS
OR
PARTNERS
NO. OF
EMPLOYED
LAWYERS
d. What was the date of establishment of the oldest “Predecessor in Business”?
Broker Name
Broker Street
Broker City, State, Zip
Evanston Insurance Company
Markel American Insurance Company
Markel Insurance Company
MALP 0001 02 17 Page 2 of 10
6. Does the Applicant have any subsidiaries, or conduct any ancillary business or
professional activities or services?
Yes No
If Yes, advise name of subsidiary or ancillary business, detailed description of operation, and amount of gross annual
revenues:
7. Staff:
Number Currently Employed
Number Who Left the Applicant
in Past Year
Lawyers
Limited License Legal Technicians*
Paralegals
Non-Lawyer Employees
*Limited License Legal Technicians or equivalent designation (authorized in Washington State) are not fully licensed
lawyers and may not represent clients in court, however they are licensed to practice and advise or assist clients in
certain specified areas of law, as prescribed by state law or regulations.
8. List all Lawyers to be insured along with the proper designation code.
Designation Codes: P = Partner L = Lawyer OC = Of Counsel IC = Independent Contractor
LT = Limited License Legal Technician or equivalent designation
NAME
DESIGNATION CODE
(If “OC“ or “IC”, indicate approximate
hours per week worked for Named
Insured)
YEAR FIRST
ADMITTED
TO BAR OR
LICENSED
AS "LT"
STATES WHERE
LICENSED
YEAR
JOINED
APPLICANT
NOTE: If Applicant has more than ten (10) lawyers and Limited License Legal Technicians, please list remainder by separate attachment.
9. Provide total gross revenues for the Applicant for the past three (3) years or fiscal
year period. If newly established, indicate anticipated gross revenues for the current
year.
$ current year
$ last year
$ 2 years ago
II. APPLICANT’S PRACTICE
1. a. Practice Areas. Describe the Applicant’s practice by showing the approximate percentage of gross billable
dollars during the past year derived from the following:
CATEGORY A
CATEGORY B
CATEGORY C
Administrative
Government Law
International Law
Appellate
Title/Commercial
Juvenile
Arbitration Title/Residential
Labor/Management
Representation
Criminal
Traffic
Immigration
Mediation
Municipal Law
SUBTOTAL A
SUBTOTAL B
SUBTOTAL C
MALP 0001 02 17 Page 3 of 10
CATEGORY D
CATEGORY E
CATEGORY F
Litigation:
Civil Rights
Admiralty
Plaintiff: BI/PI
Foreign Law
Antitrust
Class Action +
Guardianships
Banking
Mass Tort +
Commercial Law
Medical
Malpractice +
Corporate Formation
Other Litigation
Foreclosures +
Defense: Class Action +
General Corporate Advice
Mass Tort +
Lobbying
Insurance
(Excluding Med
Mal)
Tax Preparation
Medical
Malpractice
Other BI/PI
Other Litigation
SUBTOTAL D
SUBTOTAL E
SUBTOTAL F
CATEGORY G
CATEGORY H
CATEGORY I
Bankruptcy
Entertainment+
Adoptions
Collection +
Fiduciary
Environmental Law +
Construction
Investment
Counseling +
High Profile Divorce (greater
than 10 Million Marital Assets)
Estate Planning
Labor/Union
Representation +
Limited Partnership
Formation ++
Estate, Trust, Wills
Mergers/Acquisitions
(Corporate) +
Oil/Gas/Mining +
Family Law
Purchase/sale of
business
Real Estate Development +
Patent, Trademark,
Copyright Litigation +
Tax Opinions
SUBTOTAL G
SUBTOTAL H
SUBTOTAL I
CATEGORY J
CATEGORY K
CATEGORY L
Real Estate Syndication
Real estate
closings/general
Tribal Law
Securities / Bonds ++
Patent, Trademark, Copyright
Prosecution or Searches +
Water Law
SUBTOTAL J
SUBTOTAL K
SUBTOTAL L
+ Complete the appropriate supplemental application if any percentage within the last two (2) years.
++ Complete the appropriate supplemental application if any percentage within the last five (5) years.
NOTE - Total of Categories A through L must equal 100%
b. With respect to the Applicant's litigation practice, what is the approximate average caseload per
attorney (annually)?
c. With respect to the Applicant’s litigation practice, when accepting a case in an uncommon venue or
jurisdiction, what procedures are utilized to ensure that statutes of limitations and other deadlines are properly
identified?
________________________________________________________________________________________
________________________________________________________________
_________________________
MALP 0001 02 17 Page 4 of 10
d. Does an attorney meet with every client prior to accepting the representation of that client?
If no, please explain in complete detail on a separate sheet.
Yes No
2. Check each box below if, at any time during the past year, you have represented or provided any kind of legal
service to any of the dual or multiple parties shown below, relative to the same basic matter or transaction:
Buyer and Seller
Corporation and Individual Shareholders
Employer and Employee
Franchisor and Franchisee
Husband and Wife in divorce
Investors and Real Estate Developers
Lender and Borrower
Licensor and Licensee
Please attach detailed description relative to each box above that is checked, including but not limited to complete
conflict of interest disclosure procedures utilized with each party and whether each individual party consented to
such dual or multiple representation in writing or not.
3. a. Securities Related Activities. Indicate if any past or present lawyer in any way associated
with the Applicant has had any involvement in the following areas within the past five (5)
years:
i. Registration, issuance, offering, or sale of any bonds or securities.
If Yes, please complete the Supplemental Securities Application.
Yes No
ii.
Promoter, syndicator, general partner, or managing general partner of any limited
partnership.
If Yes, please complete the Limited Partnership Supplemental Application.
Yes No
b. Business Related Activities. Indicate if any past or present lawyer in any way associated with the
Applicant has had any involvement in any of the following areas within the past two years:
i. Discretionary investment authority over client funds, except for wills and trusts.
Yes No
ii.
Deal maker. Locate potential investors, buyers, partners or lenders for any project,
business, or other venture.
Yes No
iii. Due diligence on behalf of a prospective buyer of a business.
Yes No
iv. Drafted or negotiated any terms of any buy-sell agreement involving cash or stock, relati
ve to
the purchase of any business, corporate stock or assets, or any commercial property or real
estate, where the values involved were $5,000,000 or more?
Yes No
v. Accept compensation on a commission basis or based on dollar value of sale.
Yes No
c. If Yes to 3.b.i. through 3.b.v., please complete the Business Related Activities
Supplement.
4. Business Involvements with Clients/Outside Interests. For all past or present clients of the
Applicant, has the Applicant or any predecessor in business or any lawyer or employee thereof
within the past two (2) years served as a director, officer, or employee, or had any kind or
amount of equity or ownership interest in the client, or engaged in any kind of business venture
with the client?
If “Yes”, complete the Outside Interest Supplemental Application.
Yes No
5. Within the last five (5) years, has the Applicant or any Insured ever acted as either In House
General Counsel, or as Outside General Counsel for any Publicly Owned Client?
If “Yes”, complete the Publicly Owned Clients Supplemental Application.
Yes No
Note:
For purposes of this Application, the following three definitions apply:
(1)
“In House General Counsel” means any lawyer of the Applicant who provides legal
advice or legal services as an employee or independent contractor working in the offices
of any Publicly Owned Client.
(2) “Outside General Counsel” means
the Applicant, or any lawyer of the Applicant, who
provides legal advice or legal services to any Publicly Owned Client relative to all or most
of that client’s corporate, commercial, or contractual related legal matters.
(3) “Publicly Owned Client” includes
any former or present client of the Applicant whose
outstanding stock has been sold or traded at any time via any public stock exchange.
MALP 0001 02 17 Page 5 of 10
III. CLIENT RELATIONS
1. Major Client. Did any one client (including affiliated or related clients) account for twenty-five
percent (25%) or more of your gross revenues during the past twelve (12) months?
If Yes, please provide complete details on a separate attachment.
Yes No
2. a. Suits for Fees. How many suits for collection of fees have been filed against clients in the
last two (2) years?
______________
b. Provide the following information on each suit for unpaid legal fees filed within the last two (2) years. Please
attach separate sheet if necessary:
DATE
FILED
NAME OF CLIENT
$ AMOUNT
SOUGHT
STATUS/RESULT
c. What steps have been taken by the Applicant to reduce or avoid the necessity of future fee collections suits?
d. When evaluating whether a case should be sent for collection, does the Applicant review the
file for the
purpose of evaluating whether the possibility of a counterclaim alleging
malpractice might be filed in response thereto?
Yes No
3. Insolvent Clients. Please check the applicable box(s) if any past or present client for whom you
provided any kind of legal service or advice subsequently became insolvent, bankrupt, or went
into liquidation or receivership during the past two (2) years unless your representation was
solely limited to bankruptcy work:
a. At any time, had you been corporate counsel or general counsel for the client?
Yes No
b. Was client publicly owned, or had its stock been traded on any stock exchange? Yes No
c. Was client any type of financial institution, financial services company, insurance company,
or investment company?
Yes No
d. Did the Applicant provide any environmental, investment counseling, patent, real estate or
securities legal service advice to the client?
Yes No
If Yes to any part of Question 3, please provide complete details on a separate attachment.
4. Financial Institution Clients. During the past two (2) years, have you provided any of the
following services to any type of Financial Institution client?
a. Acted as general counsel?
Yes No
b. Served on any executive or loan committee?
c. If Yes to Question 4.b., did you approve loans for any of the Applican
t's clients, the
Applicant or its employees, their spouses or individuals known to be family members of an
Applicant's employee?
Yes No
Yes No
d. Performed any commercial loan due diligence or commercial loan documentation work?
Yes No
If Yes, please complete the Financial Institution Supplemental Application.
IV. APPLICANT MANAGEMENT AND ADMINISTRATION
1. General. Does the Applicant have and actively use the following:
a. Full time office administrator.
Yes No
b. Formalized professional liability risk management program.
Yes No
c. CPA audited or CPA compiled annual financial statement.
Yes No
d. Fidelity Bond.
Yes No
e. Formalized peer review program or procedure.
Yes No
f. Standard pre-printed new client interview forms.
Yes No
g. Engagement letters on new clients and new matters.
Yes No
h. Disengagement or non-engagement letters.
Yes No
i. Second factor authorization via phone before releasing any wire transfer instruction.
Yes No
MALP 0001 02 17 Page 6 of 10
2. a. Does the Applicant ever sub-contract or refer any kind of work to other law firms or other
third parties?
If Yes, what is the total percentage of work that is sub-contracted %
Yes No
b. If Yes, does the Applicant require and confirm that the subcontracting entity carries separate
errors and omissions insurance?
c. Please attach a separate sheet detailing what kind of work is sub-contracted or referred,
and what steps are taken to protect the Applicant from suits due to the errors and omissions
of the firm to whom the client is referred.
Yes No
3. Internet Activity. Is the Applicant involved "on-line", other than attorney-client e-mail, in the following activities?
a. Marketing for new clients and accepting new clients.
Yes No
b. Providing any legal services or advice to anyone.
Yes No
c. Providing case status updates to clients.
Yes No
d. Maintenance of any legal bulletin boards or chat rooms.
Yes No
e. Use cloud services (data or documents) housed by a 3
rd
party.
Yes No
f. Briefly describe the efforts to ensure the security of the Applicant’s data, documents, website and/or related
electronic communication. ______________________________________________________________
4. Computerization/Automation. Check each of the below functions or areas for which the Applicant is automated or
computerized:
Accounts Receivable Management
Expert Systems
Legislative Tracking
Attorney Timekeeping
Financial Management
Litigation Support
Billing
In-house Work Products Index
Other
____________________
Case Management Systems
Legal Research
5. Diary System/Docket Control. Check each of the below methods used by the Applicant along with other factors
that apply:
Computer
Perpetual Calendar
Tickler
Day timer
Pocket Calendar
No Formal System
System is centralized and used by the Applicant members.
System tracks court dates and deadlines and statute of limitations dates.
Software calculates/identifies all key dates upon initial entry of a matter.
Open calendar entries are circulated to all lawyers on a weekly basis.
6. Conflict of Interest System/Conflict Avoidance. Check each of the below methods used by the Applicant along
with other factors that apply:
Computer
Oral/Memory
No Formal System
Multiple Index Files
Single Index Files
System is centralized and used by the Applicant members.
System retains and checks client name, client's principals and subsidiaries, opposing party and opposing counsel.
V. PRIOR INSURANCE INFORMATION (Check here if None )
1. List the Lawyers Professional Liability insurance purchased for each of the past three (3) years, including periods
of no coverage:
POLICY PERIOD
INSURANCE
COMPANY
LIMIT OF LIABILITY
PER CLAIM/
AGGREGATE
DEDUCTIBLE
(IF ANY)
NO. OF
LAWYERS
COVERED
PREMIUM
FROM:
MM/DD/YY
TO:
MM/DD/YY
$ $ $
$
$
$
$ $ $
MALP 0001 02 17 Page 7 of 10
2. a. Does your current policy contain a prior acts limitation or a retroactive date?
Yes No
b. If Yes, indicate the date and attach a copy of your current policy’s prior acts endorsement and Declarations
Page:
3. MISSOURI APPLICANTS DO NOT ANSWER THIS QUESTION.
a. Has the Applicant or any prede
cessor in business or any lawyer ever had any Insurer
decline, cancel, refuse to renew, or accept only on restricted terms any Professional Liability
Insurance, or has the Applicant or any individual lawyer ever purchased an extended
reporting period endorsement?
b. If Yes, please attach complete details on a separate sheet.
Yes No
VI. DISCIPLINARY PROCEEDINGS AND CLAIM ACTIVITY
IMPORTANT NOTICE: All known claims and/or circumstances that could result in a Pro
fessional Liability
claim are specifically excluded from coverage. Report all such claims and/or circumstances to your current
insurer. If any circumstance, act, error, or omission exists that could result in a professional liability claim,
then such claim and/or any claim arising from such act, error, omission or circumstance is excluded from
coverage that may be provided under this proposed insurance.
1. a.
Has any Applicant member, past or present, ever been refused admission to practice,
disbarred, suspended, reprimanded, sanctioned, fined, or held in contempt by any court,
state or local bar association, administrative agency, or regulatory body?
Yes No
b. If Yes, please provide complete details on a separate sheet, including a copy of the courts
final opinion.
2. a.
To Applicant’s knowledge, has any Applicant member had a disciplinary complaint or
grievance made to any court, bar association, administrative agency or regulatory body in the
last five (5) years that resulted in any formal censure or other formal action?
Yes No
b. If Yes, please provide complete details on a separate sheet.
3. a. Has any professional liability claim or suit been made in the past five (5) years against the
Applicant or its predecessor(s) in business or any current or former member of the Applicant
or its predecessor(s) in business?
Yes No
b. If Yes, indicate total number of claims:
c. After inquiry, does any Applicant member know of any circumstance, situation, act, error or
omission that could result in a professional liability claim or suit against the Applicant or its
predecessor(s) in business or any of the current or former members of the Applicant or its
predecessor(s) in business?
Yes No
d. If Yes, indicate total number of such incidents:
If Yes to any part of Question 3, a Supplemental Claim Form must be completed for each claim or
incident in order for your Application to be considered.
VII. COVERAGE REQUESTED
LIMIT OF LIABILITY
Each claim / Aggregate
$ 250,000 / $ 250,000 (N/A in AR, NJ, NM, NY, SD)
$ 500,000 / $ 500,000 (N/A in AR, NJ, SD)
$ 1,000,000 / $ 1,000,000
$ 1,000,000 / $ 2,000,000
$ 1,000,000 / $ 3,000,000
$ 2,000,000 / $ 2,000,000
$ 2,000,000 / $ 4,000,000
$ 3,000,000 / $ 3,000,000
$ 4,000,000 / $ 4,000,000
$ 5,000,000 / $ 5,000,000
Claims expenses
Included within the Limits of Liability
Have separate Limits of Liability
MALP 0001 02 17 Page 8 of 10
AGGREGATE DEDUCTIBLE
This is the total of your contribution for all reported claims in any policy year.
$ 2,500
$ 5,000
$ 10,000
$ 25,000
Other Specify amount $
PLEASE PROVIDE ADDITIONAL COMMENTS THAT WOULD FURTHER CLARIFY THE INFORMATION ABOVE
OR ADDRESS CHARACTERISTICS OF YOUR PRACTICE NOT SPECIFICALLY ADDRESSED HEREIN.
By signing this Application, you represent and agree to each of the following five (5) items:
1.
You have made a comprehensive internal inquiry or investigation to determine whether any member of the
Applicant is aware of any actual or alleged fact, circumstance, situation, act, error or omission which may
reasonably be expected to result in a claim, and have fully and completely divulged any and all such situations in
Section VI. of this Application; and
2.
This Application, along with each of the following applicable Supplemental Applications, are hereby being
submitted to the Company. (Please check all that apply):
Bond Supplemental App
Labor Union Supplemental App
Business Related Activities Supplemental App
Limited Partnership Formation Supplemental App
Claim Information Supplemental Application(s)
Medical Malpractice – Plaintiff Supplemental App
Class Action and Mass Tort Supplemental App
New Lawyers Supplemental Application(s)
Collection Work Supplemental App
Oil/Gas/Mining Supplemental App
Corporate Mergers & Acquisitions Supplemental App
Outside Interest Supplemental App
Entertainment Supplemental Application
Prior Acts Ext. – Specified Lawyers at Specified Firms
Environmental Practice Area Supplemental App
Publicly Owned Clients Supplemental App
Financial Institution Supplemental App
Real Estate Development Supplemental App
Foreclosure Supplemental App Securities Supplemental App
Intellectual Property Supplemental App
Title Agency Supplemental App
Investment Counsel/Money Mgmt Supplemental App
Other:
3.
Each of the statements and answers given in this Application, and in each of the Supplemental Applications
checked in Number 2. above, are:
a. Accurate, true and complete to the best of your knowledge;
b.
No material facts have been suppressed or misstated;
c.
Representations you are making on behalf of all persons and entities proposed to be insured;
d.
A material inducement to the insurance company to provide insurance, and any policy issued by the insurance
company is issued in specific reliance upon these representations.
4. THIS PARAGRAPH DOES NOT APPLY TO NORTH CAROLINA, UTAH OR WISCONSIN APPLICANTS. This
Application, along with each of the Supplemental Applications checked in Number 2. above, are hereby deemed to
be attached to the policy contract, and
incorporated into the policy contract, whether or not any of the
Supplemental Applications are physically attached to a particular copy of the policy contract, and regardless of
whether any of the Supplemental Applications are signed or dated.
5. You agree to promptly report to the Company, in writing, any material change in your operations, conditions, or
answers provided in this Application, or any Supplemental Application, that may occur or be discovered after the
completion date of said Application(s), but before the inception date of the policy. Upon receipt of any such written
notice, the Company has the right, to modify or withdraw any proposal for insurance.
MALP 0001 02 17 Page 9 of 10
IMPORTANT NOTICE: Failure to report any claim made against you during your current polic
y term, or facts,
circumstances or events which may give rise to a claim against you to your current insurance company BEFORE
expiration of your current policy term may create a lack of coverage. Please see IMPORTANT NOTICE in Section VI.
COMPLETION OF T
HIS FORM DOES NOT BIND COVERAGE. APPLICANT’S ACCEPTANCE OF COMPANY’S
QUOTATION IS REQUIRED PRIOR TO BINDING COVERAGE AND POLICY ISSUANCE. IT IS AGREED THAT
THIS FORM SHALL BE THE BASIS OF THE CONTRACT SHOULD A POLICY BE ISSUED, AND IT WILL ATTACH
TO THE POLICY.
NOTICE:
By applying for this insurance, the applicant also is applying for membership in Premier Attorneys
Purchasing Group, Inc., a purchasing group formed and operating pursuant to the Federal Liability Risk Retention Act
of 1986 (15 USC 3901 et seq.). This purchasing group was formed for the sole purpose of providing professional
errors and omissions liability insurance to lawyers. The sole purpose of becoming a member is to purchase
professional liability insurance.
NOTICE TO FLORIDA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE,
DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING
ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY IN THE THIRD DEGREE.
NOTICE TO NEW YORK APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY
INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF
CLAIM 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, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED
FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.
An authorized representative who is an active owner, officer, or partner of the Applicant must sign this Application
within sixty (60) days prior to the policy inception date.
Signature of Owner, Officer or Partner
Date
Print or Type Name and Title
PRODUCERS MUST COMPLETE:
PRODUCED BY (Insurance Agent or Broker):
Producer Name: Producer Signature:
Producer License No.: Date:
click to sign
signature
click to edit
click to sign
signature
click to edit
MALP 0001 02 17
Page 10 of 10
FRAUD WARNINGS:
NOTICE TO APPLICANTS: (Not applicable to applicants in AL
AR, CO, DC, FL, KS, KY, LA, MD, ME, NJ, NM, NY, OH, OK, PA, RI, TN,
VA, VT, WA or WV.) Any person who knowingly and with intent to defraud any insurance company or another per
son files an
application for insurance, or statement of claim 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 and
may subject the person to
criminal and civil penalties.
NOTICE TO ALABAMA APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM F
OR
PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANC
E
IS GUILTY OF A CRIME AND MAY BE SUBJECT TO RESTITUTION, FINES,
OR CONFINEMENT IN PRISON, OR ANY COMBINATION
THEREOF.
NOTICE TO ARKANSAS, DISTRICT OF COLUMBIA, NEW MEXICO, RHODE ISLAND AND WEST VIRGINIA APPLICANTS:
ANY
PERSON WHO KNOWINGLY PRESENTS A FAL
SE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT, OR
KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE
SUBJECT TO FINES AND CONFINEMENT IN PRISON.
NOTICE TO COLORADO APPLICANTS: IT IS UNLAWFUL TO KN
OWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS
OR INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE
COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES, DENIAL OF INSURANCE AND CIVIL DAMAGES. ANY INSURANC
E
COMPANY OR AGENT OF AN INSURANCE COMPANY WHO KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING
FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO
DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTL
EMENT OR AWARD PAYABLE FROM INSURANCE
PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY
AUTHORITIES
NOTICE TO KANSAS APPLICANTS:
IT IS UNLAWFUL TO COMMIT A “FRAUDULENT INSURANCE ACT” WHICH MEANS AN ACT
CO
MMITTED BY ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE PRESENTED OR
PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER,
BROKER OR ANY AGENT THEREOF, ANY WRITTEN, ELECTRONIC, E
LECTRONIC IMPULSE, FACSIMILE, MAGNETIC, ORAL, OR
TELEPHONIC COMMUNICATION OR
STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR
THE RATING OF AN INSURANCE POLICY FOR PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OT
HER
BENEFIT PURSUANT TO AN INSURANCE POLICY FOR COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS
TO CONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT MATERIAL THERETO; OR CONCEALS, FOR THE
PURPOSE OF MISLEADING, ANY INFORMATION CONCERNING ANY FACT MATERIAL THERETO.
NOTICE TO KENTUCKY APPLICANTS:
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 O
F MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A
FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
NOTICE TO MAINE, TENNESSEE, VIRGINIA AND WASHINGTON APPLICANTS:
IT IS A CRIME TO KNOWINGLY PROVIDE FALSE,
INCOMPLETE OR MISLEADING INFORMA
TION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE
COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES OR A DENIAL OF INSURANCE BENEFITS.
NOTICE TO MARYLAND APPLICANTS: ANY PERSON WHO KNOWINGLY OR
WILLFULLY PRESENTS A FALSE OR FRAUDULENT
CLAIM FOR PAYMENT OF A LOSS BENEFIT OR WHO KNOWINGLY OR
WILLFULLY PRESENTS FALSE INFORMATION IN AN
APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.
NOTICE TO NEW JERSEY APPLICANTS: ANY PERSON WHO INCLUDES ANY F
ALSE OR MISLEADING INFORMATION ON AN
APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.
NOTICE TO OHIO APPLICANTS
: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A
FRAUD AGAINST AN INSURER, SUBMITS AN
APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT
IS GUILTY OF INSURANCE FRAUD.
NOTICE TO OKLAHOMA APPLICANTS:
WARNING: ANY PERSON WHO KNOWINGLY, AND WITH INTENT TO INJURE, DEFRAUD OR
DECEIVE ANY INSURER, MAKES ANY CLAIM FOR THE PROCE
EDS OF AN INSURANCE POLICY CONTAINING ANY FALSE,
INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY.
NOTICE TO PENNSYLVANIA APPLICANTS:
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE
COMPANY OR OTHER PERSON FILES AN APPLICATION F
OR INSURANCE OR STATEMENT OF CLAIM 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 AND SUBJECTS SUCH PERSON TO
CRIMINAL AND CIVIL PENALTIES.
NOTICE TO VERMONT APPLICANTS:
ANY PERSON WHO KNOWINGLY PRESENTS A FALSE STATEMENT IN AN APPLICATION
FOR INSURANCE MAY BE GUILTY OF A CRIMINAL OFFENSE AND SUBJECT TO PENALTIES UNDER STATE LAW.
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Broker Name Evanston Insurance Company Broker Street Markel (Risk Placement Services, Inc.)

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Completed 30 July 2020

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