Fillable Mass Tort Class-Action Supplemental Application

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Mass Tort Class-Action Supplemental Application

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Page 1 of 4
MASS TORT/CLASS ACTION SUPPLEMENTAL APPLICATION
(At your option, you may also attach a narrative description of your office’s mass tort/class action practice.)
1. Firm Name:
2. List all attorneys in the firm who handle mass tort or class action cases?
3. What types of mass tort or class action cases do you handle (details regarding issues, type of products, etc.)?
(Use extra pages if needed to describe fully.)
4. How many mass tort or class action cases does your practice currently have open?
5. How many mass tort or class action cases has your practice closed during the past 5 years?
6. For all mass tort or class action cases that are currently open, please provide the following information (use
extra pages if needed):
Defendant
Name
Allegation
made
# of
Members
States the
Class is
filed in
Is this a
Nationwide
Class
Dollar value/
Potential
Damages of
Class
Specify if
Lead/Local/
Co-Counsel/
Referral Attorney
GENERAL INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 4
7. For all mass tort or class action cases that closed during the past 24 months (including favorable and
unfavorable judgments and those dismissed), please provide the following information (use extra pages if
needed):
Defendant
Name
Allegation
made
# of
Members
States the
Class is
filed in
Is this a
Nationwide
Class
Dollar value/
Potential
Damages of
Class
Specify if
Lead/Local/
Co-Counsel/
Referral Attorney
8. If cases are referred to other firms, are these other firms in other juridictions? Yes No
If so, where?
9. Do you retain a fee for such referrals? Yes No
10. Do you continue to work on the case after referral? Yes No
11. If you are not the sole attorney, do you send your clients outlining the specific scope Yes No
of your representation? (i.e., advising them which tasks you are or are NOT performing, etc.)
If No, please explain why not:
12. Please describe how you handle class members who choose to opt out of the class to pursue an individual
claim (including describing the risks involved in writing, who handles the case, is it referred elsewhere, etc.).
13. If there is any other information that you believe would be helpful in understanding more about your mass
tort or class action cases or experience, please elaborate.
14. Has any claim or potential claim been made to you, your practice (past or present), any Yes No
lawyer employed by your firm, or any insurance carrier regarding any mass tort or class
action case that you have handled at this time? If Yes, please attach a narrative explanation.
15. Do you have knowledge of any circumstances or events that could give rise to a potential Yes No
claim arising out of any mass tort or class action cases that you, your practice (past or present),
any lawyer employed by your firm has ever handled? If Yes, please attach a narrative explanation.
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 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.
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 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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Mass Tort Class-Action Supplemental Application

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Completed 2 July 2020

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