Fillable CLASS ACTION AND MASS TORT LITIGATION SUPPLEMENTAL APPLICATION (Risk Placement Services, Inc.)

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CLASS ACTION AND MASS TORT LITIGATION SUPPLEMENTAL APPLICATION (Risk Placement Services, Inc.)

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MALP 0006 02 17 Page 1 of 2
CLASS ACTION AND MASS TORT LITIGATION SUPPLEMENTAL APPLICATION
NOTE: For purposes of this Supplemental Application, the term “Class Action” includes any lawsuit which was or is
expected to be certified as a class action in any state or federal court and “Mass Tort” includes any lawsuit brought or
maintained by or on behalf of 5 or more plaintiffs.
APPLICANT’S INSTRUCTIONS:
This form is to be completed if Applicant showed any activity for the “Class Action” or “Mass Tort” component under
Section II., Applicant’s Practice, of the Policy Application. If space is insufficient to answer any question fully, attach a
separate sheet. Answer all questions completely.
APPLICANT:
1.
a. Do you anticipate participating in or having any involvement in any additional or new class action or
mass tort lawsuits during the next twelve months?
Yes No
b. Relative to each of the class action and mass tort cases you have been involved in during the last
two (2) years or are currently involved in, please complete the following:
INFORMATION NEEDED
CASE #1
CASE #2
Name of Client:
Name of Case – Name of Plaintiffs and Defendants:
Has the class been “Certified”?
Has an offer of Settlement been made by any Defendant?
Yes No
Yes No
Yes No
Yes No
Date of Verdict/Settlement, if applicable:
Was this case a Verdict or Settlement:
Total dollar amount of Verdict/Settlement:
What was the subject of the lawsuit?
Approximate total number of class members/plaintiffs:
Were you sole counsel or co-counsel?
If Settlement, was fairness hearing held, or was it otherwise
formally court approved?
Yes No Yes No
Has Verdict/Settlement been collaterally attacked by anyone?
If Yes, please explain below.
Yes No Yes No
Is your client or any co-defendant bankrupt or insolvent?
If Yes, please explain below.
Yes No Yes No
If additional space is needed, please provide details on a separate attachment.
I understand the information submitted herein becomes a part of my Professional Liability Insurance Application and is
subject to the same representations and conditions.
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.
Signature of Owner, Officer or Partner Print or Type Name and Title Date (month-day-year)
Broker Name
Broker Street
Broker City, State, Zip
Deerfield Insurance Company
Evanston Insurance Company
Essex Insurance Company
Markel American Insurance Company
Markel Insurance Company
Associated International Insurance Company
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MALP 0006 02 17 Page 2 of 2
Producers Must Complete:
Produced By (Insurance Agent or Broker):
Producer Name: Producer Signature:
Producer License No.: Date:
Notice to Alabama Applicants; Any person who knowingly presents a false or fraudulent claim for 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, 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 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 claiming with regard to a settlement or award payable for insurance
proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
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, 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 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 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 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 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 or 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.
Notice to Applicants of all other states: 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 the person to criminal and civil penalties.
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CLASS ACTION AND MASS TORT LITIGATION SUPPLEMENTAL APPLICATION (Risk Placement Services, Inc.)

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Completed 23 November 2020

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