Fillable Employed Lawyers Protection Plus (Philadelphia Insurance Companies)

Fill Online, Printable, Fillable, Blank Employed Lawyers Protection Plus (Philadelphia Insurance Companies) Form

Use Fill to complete blank online PHILADELPHIA INSURANCE COMPANIES pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Employed Lawyers Protection Plus (Philadelphia Insurance Companies)

On average this form takes 25 minutes to complete

The Employed Lawyers Protection Plus (Philadelphia Insurance Companies) form is 5 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 98 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Philadelphia Insurance Companies forms online.

BROWSE PHILADELPHIA INSURANCE COMPANIES FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Page 1 of
5
___________________________________________________________________________
Name of Insurance Company to which Application is made (herein called the “Insurer”)
Employed Lawyers Protection Plus
EMPLOYED LAWYERS PROFESSIONAL LIABILITY APPLICATION
NOTICE: THE POLICY PROVIDES THAT THE LIMITS OF LIABILITY AVAILABLE TO PAY
JUDGMENTS OR SETTLEMENTS SHALL BE REDUCED BY DEFENSE COSTS. FURTHER NOTE THAT
AMOUNTS INCURRED FOR DEFENSE COSTS SHALL BE APPLIED AGAINST THE RETENTION
AMOUNT.
THIS APPLICATION DOES NOT BIND THE APPLICANT TO BUY OR THE INSURER TO ISSUE THE
INSURANCE, BUT IT IS AGREED THAT THIS FORM SHALL BE THE BASIS OF THE CONTRACT
SHOULD A POLICY BE ISSUED, AND IT WILL BE ATTACHED TO AND BECOME PART OF THE POLICY.
IF A POLICY IS ISSUED, IT WILL BE ON A CLAIMS-MADE BASIS.
1. Name of the Applicant:_______________________________________________________________________
2. Address of the main office of the Applicant:
__________________________________________________________________________________________
__________________________________________________________________________________________
Note: (Applicant shall include any and all of Applicant’s Subsidiaries) All bolded terms have the same
meaning as the same terms in the Employed Lawyers Protection Plus policy
3. Date of formation or incorporation: ____________________________
4. State of formation or incorporation: ____________________________
5. Primary Nature of Business (include SIC class):
6. Applicant is a Public Private Not For Profit entity.
Also, please give the average time of service of your
directors: _______________ years
If Public, please provide the exchange where you are listed and symbol: _______________________
7. Number of full time In-House Counsel employed by the Applicant: _______________________
8. Number of part time In-House Counsel employed by the Applicant: _______________________
9. Number of Independent Contractor Counsel contracted by the Applicant: _______________________
10. Limit of liability requested: $_______________________
11. Retention requested (each claim for indemnifiable loss): $_______________________
PI-EW-APP FL (05/10)
Print Application
Clear Application
If a Securities Claims Sublimit of Liability is requested, then these questions must be answered:
S1. Does any In-House Counsel issue legal opinions with respect to registration statements filed with any
securities commission? Yes No
S2. Does any In-House Counsel sign registration statements of the Applicant? Yes No
S3. Does any In-House Counsel serve on the Board of Directors or equivalent governing body of the Applicant?
Yes No
S4. Has the Applicant made a public offering of debt or equity within the past two (2) years? Yes No
S5. If Applicant is a private company, does it have a filing requirement with the U.S. Securities and Exchange
Commission? Yes No
PI-EW-APP FL (05/10) Page 2 of 5
12. Securities Claims Sublimit of Liability requested:
$
(maximum $5,000,000)
13. Does Applicant plan
to merge, acquire, or be acquired by or with another entity or consolidate any of its
Subsidiaries within the next twelve (12) months? Yes No
14. Does Applicant anticipate any registration of securities under the Securities Act of 1933 (or any similar state or
foreign rule or law) or any other offering of securities within the next twelve (12) months? Yes No
15. Does any In-House Counsel issue written legal opinions to outside parties in connection with sales, acquisitions
or other transactions? Yes No
16. Does any In-House Counsel serve on a due diligence committee or perform legal professional services in
connection with any of Applicant’s mergers, acquisitions or consolidations? Yes No
17. Does any In-House Counsel appear in court for the Applicant or other parties in the course of his employment
for the Applicant? Yes No
18. Does any In-House Counsel provide personal legal professional services with respect to criminal, matrimonial
or intellectual property law or estate/financial planning? Yes No
If “yes,” how often?
19. Financial information (A financial statement is required if limits of more than $1 million are requested):
Total Assets:
$
Total Liabilities: $
Current Assets: $
Current Liabilities: $
Revenues: $
Based on financial statement dated: / / (Month / Year)
Print Application
Clear Application
Page 3 of
5
20. Does the Ap
plicant carry Directors and Officers, Employment Practices Liability, Professional Liability Insurance?
Yes No
If “Yes,” provide the following information with regard to all insurance:
D&O EPLI E&O
Insurance carrier
Limits of liability $ $ $
Deductible/Retention $ $ $
Premium $ $ $
Policy Period
Retroactive date/Continuity date
Years of continuous coverage
21. Has any insurance carrier refused, canceled or non-renewed the Applicant’s Directors and Officers or other
management liability insurance, Employment Practices Liability insurance or Professional Liability insurance for
In-House Counsel? (MISSOURI APPLICANTS NEED NOT REPLY) Yes No
If “Yes,” please provide the date, carrier, coverage and reason for each declination, cancellation or non-
renewal.
22. Has any In-House Counsel been subject to any discipline by, or been refused admission to any bar, court or
administrative agency? Yes No If “Yes,” attach complete information.
23. Has the Applicant or any In-House Counsel been charged with a violation of any federal, state or foreign
securities law, rule or regulation in any court or by any civil, criminal, administrative or regulatory agency?
Yes No If “Yes,” attach complete information.
24. After reasonable inquiry, is any In-House Counsel or the Applicant aware of any claims or actions against any
person proposed for insurance in his or her capacity as In-House Counsel within the past three (3) years?
Yes No If “Yes,” attach complete information.
25. After reasonable inquiry, is any In-House Counsel or the Applicant, aware, of any act, error or omission which
may reasonably be expected to give rise to a claim against any In-House Counsel? Yes No
If “Yes,” attach complete information.
It is agreed that with respect to questions 22, 23, 24 and 25 above, that if any answer is in the affirmative, then
such Claim, proceeding or action and any Claim or action arising from such Claim, proceeding, action,
knowledge, information or involvement is excluded from the proposed coverage. It is further agreed that all written
statements and materials furnished to the insurer in conjunction with this Application along with all public
documents (including 10-Qs, 10-Ks and other filings) are hereby incorporated by reference into this application and
made a part hereof.
WARNING: 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 CONCEA
LS FOR THE PURPOSE OF MISLEADING,
INFORMATION C
ONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT,
WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.
PI-EW-APP FL (05/10)
Print Application
Clear Application
PI-EW-APP FL (05/10) Page 4 of 5
FRAUD NOTICE STATEMENT
Name (Please Print/Type) Title (Must be signed by the President, Chairman, or
General Counsel)
_______________________________________
Signature Date
The above signed warrants that he/she is authorized and has the power to complete and execute this Application,
including the Warranty Statement on behalf of the Applicant and their respective Directors, Officers or other
insured persons.
Produced By: (Section to be completed by Producer/Broker)
Producer Agency
Producer License Number Agency Taxpayer ID or SS Number
Address (Street, City, State, Zip)
RESIDENTS OF FLORIDA RESIDENTS 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 OF THE THIRD DEGREE.”
Clear Application
Print Application
Page 5 of 5
ADDITIONAL INFORMATION
This page may be used to provide additional information to any question on this application. Please
identify the question number to which you are referring.
__________________________________________
Signature Date
PI-EW-APP FL (05/10)
Clear Application
Print Application
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Employed Lawyers Protection Plus (Philadelphia Insurance Companies)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 7 November 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document