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MALP 0024 02 17 Page 1 of 7
Broker Name
Evanston Insurance Company
Broker Street
Markel American Insurance Company
Broker City, State, Zip
Markel Insurance Company
LAWYER’S ERRORS & OMISSIONS LIABILITY INSURANCE RENEWAL APPLICATION
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:
3. a. Telephone Number: b. Fax Number:
c. Website Address:
4. Date Established:
5. Staff:
Number Currently Employed
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.
6. 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.
MALP 0024 02 17 Page 2 of 7
II. APPLICANT’S PRACTICE
1. 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
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
MALP 0024 02 17 Page 3 of 7
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%
2. Before releasing any wire transfer instruction is a second factor authorization received via phone?
3. Have there been any changes/enhancements made in the following areas of firm management and
administration since your last application:
a. Acceptance of New Clients/Client Screening?
b. Diary System/Docket Control?
c. Conflict of Interest System/Conflict Avoidance?
d. Other?
If "Yes" to 2.a. through 2.d., please explain in complete detail on a separate sheet.
Yes No
Yes No
Yes No
Yes No
Yes No
4. a. Has there been any new director officer, employee or equity interest position accepted with a
client since your last application?
b. Has there been any recently acquired equity interest or changes to any existing equity interest
percentages in firm clients since your last application?
If "Yes" to 3.a. or 3.b., please explain in complete detail on a separate sheet.
Yes No
Yes No
5. Within the last year, 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.
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?
_____________
MALP 0024 02 17 Page 4 of 7
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 year 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 year, have you provided any of the following services
to any type of Financial Institution client?
If Yes, please complete the Financial Institution Supplemental Application.
a. Acted as general counsel?
Yes No
b. Served on any executive or loan committee?
c. If Yes to Question 4.b., did you appr
ove loans for any of the Applicant'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
5. a.
Has any Applicant member, since your last application to the Company, been disbarred,
suspended, reprimanded, sanctioned, or held in contempt by any court, administrative agency
or regulatory body?
Yes No
b. If Yes, please provide complete details on a separate sheet.
c. Since the completion of your last application to the Company, has any Applicant member had a
disciplinary complaint or grievance made to any court, bar association, administrative agency
or regulatory body that resulted in any formal censure or other formal action?
Yes No
d. If Yes, please provide complete details on a separate sheet.
e.
Since the completion of your last application to the Company, 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
f If Yes, please complete a Supplemental Claim Fo
rm and confirm that the incident has been
reported to the Company.
g. Has there been a change to any open incident, claim, suit or disciplinary complaint since your
last application to the Company?
Yes No
h. If Yes, please complete a Supplemental Claim Form for each claim or circumstance detailing all
new developments.
MALP 0024 02 17 Page 5 of 7
IV. COVERAGE REQUESTED
LIMIT OF LIABILITY
Each claim / Aggregate
$ 250,000 / $ 250,000 (N/A in AR, NJ, NM, 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
AGGREGATE DEDUCTIBLE
This is the total of your contribution for all reported claims in any policy year.
$ 2,500 $ 25,000
$ 5,000 Other Specify amount $
$ 10,000
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 rea
sonably be
expected to result in a claim, and have fully and completely divulged any and all such situations in Section III.5. 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 App(s)
Medical Malpractice – Plaintiff Supplemental App
Class Action and Mass Tort Supplemental App
New Lawyers Supplemental App(s)
Collection Work Supplemental App
Oil/Gas/Mining Supplemental App
Corporate Mergers & Acquisitions Supplemental App
Outside Interest Supplemental App
Entertainment Supplemental App
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: _________________________________
MALP 0024 02 17 Page 6 of 7
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.
IMPORTANT NOTICE: Failure to report any claim made against you during yo
ur current policy 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.
COMPLETION OF THIS 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:
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MALP 0024 02 17 Page 7 of 7
FRAUD WARNINGS:
NOTICE TO APPLIC
ANTS: (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 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 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
INSURANCE 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 FALSE 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 KNOWINGLY PROVIDE FALSE, INCOMPLETE, O
R 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 INSURANCE
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 SETTLEMENT 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
COMMITTED 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, ELECTRONIC IMPULSE, FACSIMILE, MAGNET
IC, 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
OTHER 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 K
ENTUCKY 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 OF 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 INFORMATION 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 FALSE 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 PROCEEDS 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 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 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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