Fillable Individual Lawyer Area Of Practice Supplemental Application

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Individual Lawyer Area Of Practice Supplemental Application

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The Individual Lawyer Area Of Practice Supplemental Application form is 3 pages long and contains:

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Page 1 of 3
INDIVIDUAL
LAWYER/NEW HIRE APPLICATION
(TO BE SUBMITTED FOR EXISTING KINSALE PL POLICIES HIRING AN ADDITIONAL ATTORNEY)
1. Firm Name: /Current Kinsale Policy Number:
2. Attorney Name:
3. Date of Hire:
4. Date Admitted to Bar: 5. State(s) Admitted to Practice:
6. Status: Owner Employee Of Counsel Independent Contractor
7. Do you practice part-time? Yes No
If yes, average # of hours per week:
8. What percentage of time – not billings – do you spend in the following areas of practice?
Total of A+B+C+D must equal 100%
APPLICANT’S INFORMATION
A. C.
% Admiralty—Defense %
Collections
% Bankruptcy %
Entertainment, sports or celebrity*
% Criminal matters %
Oil, gas, or mining
%
Defense of personal & bodily injury &
workers compensation %
Patent, copyright or trademark (complete
Intellectual Property Supplement)
% Immigration %
Plaintiff’s rep. In litigation (complete Plaintiff
Litigation Supplement)
% Mediation %
Taxation-Personal or Corporate
% Will, estate planning, probate %
Title/Abstracting
% Family & Domestic Law
% Subtotal (A) %
Subtotal (C)
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
*If any value is entered, complete Entertainment
Related Area of Practice Application
Page 2 of 3
9. In the last five (5) years, has any professional liability claim or suit ever been made against Yes No
you individually or while employed at a prior firm?
If Yes, how many?
If Yes, please complete the Claims Supplement and provide currently valued company loss runs.
10. Do you know of any incident, act, error or omission that could result in a claim or suit against Yes No
the firm or any predecessor firm or any of the current or former members of the firm?
If Yes, please complete the Claims Supplement and provide currently valued company loss runs.
11. Have you ever been refused admission to practice, been disbarred, suspended, reprimanded, Yes No
sanctioned, or held in contempt by any court, administrative agency or regulatory body or
been subject of a disciplinary complaint made to any of the aforementioned entities?
If Yes, please provide a copy of the complaint made to the bar and a copy of their decision.
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.
B. D.
% Admiralty other than Defense %
Banking, savings & loan, or other financial
institution services
%
Corporation formation/alteration
(Non-SEC Related) %
Bonds, commercial paper, limited partnerships,
or State/Federal securities, both exempt & non-
exempt (Complete Securities Supp.)
% Environmental %
Real Estate - Commercial
% ERISA or Employee Benefits %
Real Estate - Residential
%
Investment Counseling/Money Mgt.
(Complete Financial Planning Supplement) %
Real Estate Development and/or
Syndication/Limited Partnership
% International Law %
Securities/SEC (Complete Securities Supp.)
% Labor Law %
Other(Describe in detail by attachment)
% Mergers/Acquisitions
% Utilities/Municipality
% Subtotal (B) %
Subtotal (D)
100%
Total A + B + C + D
Page 3 of 3
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 a 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.
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 application.
Applicant: ______________________________________ Title:
(Must be signed by a Principal, Partner, or Officer of the Firm)
Applicant’s Signature: _____________________________ Date:
Agent/Broker Name:
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Individual Lawyer Area Of Practice Supplemental Application

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Completed 2 July 2020

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