APPLICATION FOR LAWYERS PROFESSIONAL LIABILITY INSURANCE
D
ISCIPLINARY SUPPLEMENT
Page 1 of 2 DisciplinarySupp 2013
This supplement is to be completed by
• CNA renewal firms if a disciplinary matter was reported to CNA during the most current policy term or is being reporting
during the current renewal process
• New Business applicants who have had a disciplinary matter during their career.
Complete one supplement for each disciplinary matter. Throughout the su
pple
ment the words “complaint”, “grievance” and “matter”
are used to indicate any disciplinary inquiry, complaint or proceeding for any reason including non-payment of dues. If more space
is needed to fully answer any question please provide via attachment.
Firm Name:
1. Name lawyer(s) involved in the complaint:
2. Name of complainant:
Client
3
rd
Party
Client 3
rd
Party
3. a. When was notification received from the Disciplinar
y Commission or governing body of your state?
b. When did you respond to the governing body?
4. a. Did you report this to your insurance carrier? Yes No
b.
If reported, please provide the name of the i
nsurance carrier.
c. Date reported:
d. Is the carrier involved in representation of y
ou in this matter? Yes No
e. If the matter was not reported to your carrier please explain why.
5. a. Was this complaint made after a suit for fees w
a
s initiated? Yes No
b. Was an engagement letter used for the firm’s representation in the matter leading to the alleged act or omission?
Yes No
c. As a result of this matter, what changes have been made that will reduce the likelihood of similar complaints?
6. a. What were the allegations in the complaint? Include a descr
i
ption of the legal services rendered in the underlying matter.
