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INTELLECTUAL PROPERTY SUPPLEMENTAL APPLICATION (Risk Placement Services, Inc.)

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MALP 0012 07 13 Page 1 of 5
INTELLECTUAL PROPERTY SUPPLEMENTAL APPLICATION
NOTE: For purposes of this Supplemental Application, the term "Intellectual Property” means any original creative work
that has economic value and can be protected by law. Forms of intellectual property include, but are not limited to patents,
trademarks, copyrights, and confidential or proprietary information or trade secrets.
APPLICANT’S INSTRUCTIONS:
This form is to be completed if the Applicant showed any activity in the Patent, Trademark, and Copyright areas of practice
shown in Section II. "Applicant's Practice," on the main application. If space is insufficient to answer any question fully,
attach a separate sheet. Answer all questions completely.
APPLICANT:
1. a. Does the Applicant have a computerized conflict of interest system in place to cross-check for
conflicts between any past or present clients?
Yes No
b. Please describe in detail the procedures you have in place for the calendaring of "Intellectual
Property" related deadlines.
2. a.
Does the Applicant assume responsibility for the payment of any maintenance, annuity, or
similar fees for any of your past or present "Intellectual Property" clients?
Yes No
b. If Yes, please advise approximately how many clients you currently perform this function for and
describe the system you currently utilize to track the renewal and ensure timely payment.
3. a. Does the Applicant employ the services of any third parties to perform searches or any other
services relating to your "Intellectual Property" clients?
Yes No
4. a.
Does the Applicant use engagement letters, fee arrangements and termination letters on all
"Intellectual Property" clients?
Yes No
b. If No,
please explain the circumstances in which engagement letters are and are not used and
how you verify in writing the scope of services that you are to perform.
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
MALP 0012 07 13 Page 2 of 5
5. a. Does the Applicant expressly prohibit the acceptance of equity or other financial interest in an
"Intellectual Property" client's product or invention in exchange for legal services?
Yes No
b. If No, please explain the procedure or criteria for allowing the above.
6. Please provide a percentage breakdown for the following industries/areas of specialization regarding
the Applicant’s “Intellectual Property” clients:
a. Chemical
%
b. Computers/Software
%
c. Electronics/Semiconductors
%
d. Mechanical/Engineering/Industrial
%
e. Pharmaceutical/Medical/Biotech
%
f. Other
%
Note:
Responses Must Total 100%
7. a. When performing legal services for an "Intellectual Property" client relating to a foreign country,
does the Applicant associate with a firm in that foreign country to represent your client's interests
abroad?
Yes No
b. If Yes, what guidelines govern your selection of a foreign firm, and how do you monitor and
ensure that all deadlines and other requirements are met?
8. a.
Do you require that the Applicant’s clients clarify and acknowledge in writing the specific
territories and countries in which the "Intellectual Property" filing is to be made?
Yes No
b. If No, please explain:
9.
Please indicate an estimate of the length in time of your client affiliation for the Applicant's
"Intellectual Property" clients from the following categories:
a. Three Years and longer
%
b. One to Three Years
%
c. Six Months to One Year
%
d. Less than Six Months
%
Note: Responses Must Total 100%
10. During the past two (2) years, have you
ever done any of the following for any past or present
"Intellectual Property" client, project, matter, or transaction? Please check either Yes or No for each
question. If Yes to any part of Question 10 below, please attach complete details on a separate
sheet.
Yes No
a. Represented or provided any legal service or advice to more than one party or client, relative to
the same basic "Intellectual Property" matter or transaction?
Yes No
b. Been directly or indirectly involved financially in any business, investment, or project financing
matter with any of your "Intellectual Property" clients?
Yes No
MALP 0012 07 13 Page 3 of 5
c. Represented dual or multiple parties, or joint or multiple owners of a product, business method,
or invention involved in an “Intellectual Property” matter or transaction?
Yes No
d. Been directly or indirectly involved in any business promotional activ
ities (i.e. marketing,
licensing, royalty negotiation, etc.) with, or on behalf of, any of your “Intellectual Property”
clients?
Yes No
e. Provided professional services to any “Intellectual Property” client for whom
any Applicant
member or spouse has ever served as an officer, director, trustee, employee or partner?
Yes No
11. a. During the past two (2) years, has the Applicant, or anyone associated with the Applicant at any
time, been named as a defendant in any kind of civil litigation that is in any way related to any
past or present "Intellectual Property" client, project or venture other than has already been
disclosed by you in Section VI. of the main application?
Yes No
b. If Yes, please provide complete details on a separate sheet.
12. Please provide a percentage breakdown by billable hours of the types of services rendered in the
past year from the following categories:
a. Domestic and Foreign Searches.
%
b. Domestic Patent Litigation.*
%
c. Foreign Patent Litigation.*
%
d. Domestic Patent Prosecution/Registration.*
%
e. Foreign Patent Prosecution/Registration.*
%
f. Domestic Intellectual Property Licensing/Contracts.
%
g. Foreign Intellectual Property Licensing/Contracts.
%
h. Trademark.
%
i. Copyright.
%
j. Other - Please Describe:
_____________________
%
Note:
Responses Must Total 100%.
13. a. For a period encompassing the past two (2) years, would the annual percentage for any type of
service provided in Question 12 above differ by more than 10%.
b. If Yes please provide details of all such changes for any area(s) on a separate sheet.
Yes No
14. a. Are all patent attorneys and patent agents who are members of the Applicant experienced (i.e.,
five (5) or more years of patent related experience)?
Yes No
b. If No, are these attorneys working directly under the supervision of a senior partner who is
responsible for the overview and quality of their work?
Yes No
15. Please evaluate your five top Intellectual Property clients with regard to the following:
# of Patents
Client #
Held or Pending
1 2 3 4 5
More than 50
25 – 49
10 – 24
5 – 9
2 – 4
0 – 1
MALP 0012 07 13 Page 4 of 5
16. During the past three (3) years has the Applicant represented any client with annual sales in excess
of $100,000,000?
If Yes, please provide client name(s) and the number of years represented.
Yes No
Client Name(s)
# years represented
17. During a period encompassing the past three (3) years, indicate during each annual period the number of lawyers who
are members of the Applicant under a corresponding percentage of time billed on intellectual property transactions or
litigation:
Number of Lawyers
Annual Period
1 - 25 %
26 - 50 %
51 - 75 %
76 - 100 %
Last year
# of lawyers # of lawyers # of lawyers # of lawyers
2 years ago
# of lawyers # of lawyers # of lawyers # of lawyers
3 years ago
# of lawyers # of lawyers # of lawyers # of lawyers
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)
Producers Must Complete:
Produced By (Insurance Agent or Broker):
Producer Name: Producer Signature:
Producer License No.: Date:
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MALP 0012 07 13 Page 5 of 5
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 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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Completed 23 November 2020

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