12. What percentage of time-not income do you spend in the following areas of practice?
Total of A+B+C+D must equal 100%
A. C.
% Admiralty—Defense % Entertainment, sports or celebrity
%
Bankruptcy % Oil, gas, or mining
%
Collections % Patent, copyright or trademark (PCT)
%
Criminal matters % Plaintiff’s rep. in personal or bodily injury
%
Defense of personal or bodily injury % Plaintiff’s representation in products liability
%
Defense of workers’ compensation % Plaintiff’s representation in workers’ comp.
%
Immigration % Real Estate - Commercial
%
International Law % Real Estate - Residential
%
Mediation % Title/Abstracting
%
Will, estate planning, probate % Domestic Law
%
Family Law % Taxation – Corporate
%
Subtotal (A) %
Subtotal (C)
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 Development and/or
Syndication/Limited Partnership
%
ERISA or Employee Benefits % Securities/SEC (Complete Securities Supp.)
%
Investment Counseling/Money Mgt.
(Complete Financial Planning
Supplement)
%
Other(Describe in detail by attachment)
%
Labor—Employee relations %Subtotal (D)
%
Labor management representation
%
Taxation-individual
%
Utilities/Municipality
%
Mergers/Acquisitions
%
Subtotal (B)
Complete attached
supplemental
application for any
plaintiff’s or PCT work.
13. a. After inquiry with each person as appropriate, in the last seven (7) years, has any professional
liability claim or suit ever been made against the Firm or any predecessor firm or any current or former
member of the Firm or predecessor firm?
No Yes
If “Yes,” how many?
Please attach copies of currently valued Loss Runs
from prior carriers. If “Yes,” complete a separate Supplemental Claim Form for each claim
or suit.
b. After inquiry with each person as appropriate, do you know of any circumstances, acts, errors or
omissions that could result in a Professional Liability claim?
No Yes
c. After inquiry with each person as appropriate, has an attorney for who coverage is sought ever been
refused admission to practice, been disbarred, suspended, reprimanded, 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?
No Yes
If “Yes,” please provide a copy of the complaint made to the bar and a copy of their
decision.
* 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, may be committing a
fraudulent insurance act, and may be subject to a civil penalty or fine.
* not applicable in all states
Applicants Signature Date Producer Title
E&O-LAW-APP Page 3 of 6 7-04
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