Fillable Employed Lawyers Professional Liability Supplemental Coverage Application (Kinsale Insurance)

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Employed Lawyers Professional Liability Supplemental Coverage Application (Kinsale Insurance)

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Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
EMPLOYED LAWYERS PROFESSIONAL LIABILITY
SUPPLEMENTAL COVERAGE APPLICATION
1. Legal name of the business which is the primary applicant and will be the first named insured listed on the policy:
2. Please describe the nature of the Applicant’s business:
3. Total number of employees:
4. Primary location address:
5. County of primary location: Date business originally established:
6. Type of Company: (Corp., partnership, LLC, JV, LLP, Other)
7. Total number of branches: List all addresses for additional branches:
8. What is your web-site address? www.
1. Please provide the number of lawyers employed by the Applicant or any Subsidiary in their capacity as such for the
Applicant or any Subsidiary:
2. What is the average number of years of experience of the Applicant’s or any Subsidiary’s employed lawyers?
3. Does any employed lawyer proposed for coverage:
(a) conduct pro bono work on behalf of the Applicant or any Subsidiary? Yes No
(b) perform moonlighting services? Yes No
(c) issue written legal opinions to outside parties? Yes No
(d) serve on the board of directors of the Applicant or any Subsidiary? Yes No
(e) perform legal services regarding mergers, acquisitions or consolidations of or
by the Applicant or any of its Subsidiaries? Yes No
(f) appear in court or litigate on behalf of the Applicant, any Subsidiary or any other party? Yes No
(g) perform any securities related legal work on behalf of the Applicant or any
Subsidiary? Yes No
(h) provide legal services with respect to criminal, matrimonial, intellectual property or
estate/finance planning? Yes No
If yes to either questions 3g or 3h, please provide additional details on a separate attachment.
Limit: __________ Retention: __________
GENERAL INFORMATION
LEGAL DEPAERTMENT INFORMATION
EMPLOYED LAWYERS CURRENT COVERAGE
Page 2 of 4
Has any “Employed Lawyer” ever been the subject of a reprimand, sanction, fine or discipline by, or Yes No
been refused admission to, a bar association, court, the U.S. Securities and Exchange Commission
or any administrative agency?
If “Yes,” please provide the name of the “Employed Lawyer” and a brief explanation.
NOTE: WITHOUT PREJUDICE TO ANY OTHER RIGHTS AND REMEDIES OF THE UNDERWRITER, IT IS AGREED THAT ANY
CLAIM ARISING FROM ANY REPRIMAND, SANCTION, FINE, DISCIPLINE OR ADMISSION REFUSAL
REQUIRED TO BE DISCLOSED IN RESPONSE TO QUESTION 6.a) IS EXCLUDED FROM THE PROPOSED INSURANCE.
During the past five (5) years, has any claim or suit been made against any “Employed Lawyer” Yes No
arising out of his or her provision of legal services, whether or not such claims or suits arose out of
work performed for the Company or its subsidiaries?
If “Yes,” please complete a Claim Summary Supplement for each such claim or suit.
NOTE: WITHOUT PREJUDICE TO ANY OTHER RIGHTS AND REMEDIES OF THE UNDERWRITER, IT IS AGREED THAT ANY
CLAIM OR SUIT REQUIRED TO BE DISCLOSED IN RESPONSE TO QUESTION 6.b) IS EXCLUDED FROM THE PROPOSED
INSURANCE.
Is any “Employed Lawyer” aware of any fact, circumstance, situation, transaction, event, act, Yes No
error or omission which he or she has reason to believe may or could reasonably be foreseen to
give rise to a claim against any “Employed Lawyer” in his or her capacity as an attorney, director or
officer of the Company or its subsidiaries?
If “Yes,” please complete a Claim Summary Supplement for each such fact, circumstance, situation, transaction, event, act,
error or omission.
NOTE: WITHOUT PREJUDICE TO ANY OTHER RIGHTS AND REMEDIES OF THE UNDERWRITER, IT IS AGREED THAT ANY
CLAIM ARISING FROM ANY FACT, CIRCUMSTANCE, SITUATION, TRANSACTION, EVENT, ACT, ERROR OR OMISSION
REQUIRED TO BE DISCLOSED IN RESPONSE TO QUESTION 6.c) IS EXCLUDED FROM THE PROPOSED INSURANCE.
CLAIMS INFORMATION
Page 3 of 4
FRAUD WARNING
NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS,
MARYLAND, MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH
CAROLINA, NORTH DAKOTA, OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA,
WISCONSIN, AND WYOMING APPLICANTS: In some 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, for the purpose of misleading, conceals information
concerning any fact material thereto, may commit a fraudulent insurance act which is a crime in many states.
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 policy holder 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 DISTRICT OF COLUMBIA APPLICANTS: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of
defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false
information materially related to a claim was provided by the applicant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of
claim containing any false, incomplete or misleading information is guilty of a felony of the third degree.
NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or
benefit is a crime punishable by fines or imprisonment, or both.
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 LOUISIANA 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 MAINE 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 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 NEW MEXICO 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 civil fines and criminal penalties.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an 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 $5,000 and the stated value
of the claim for each such violation.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she 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 a 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.
NOTICE TO TENNESSEE 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 include imprisonment, fines and denial of insurance benefits.
NOTICE TO VIRGINIA 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 include imprisonment, fines and denial of insurance benefits.
Page 4 of 4
The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant warrants that
the above statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate
or omit any material facts.
The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise prior to the effective
date of any policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may be modified or
withdrawn based upon such changes at our sole discretion.
Completion of this form does not bind coverage. Applicant’s acceptance of the company’s quotation is required prior to binding coverage and policy
issuance.
All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by reference into this
application and made a part of this applications.
Applicant: Title:
(Must be signed by General Counsel, CFO, CEO or Risk Manager of the Firm)
Applicant’s Signature: Date:
Agent/Broker Name:
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Employed Lawyers Professional Liability Supplemental Coverage Application (Kinsale Insurance)

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Completed 18 July 2020

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