Fill - Free fillable Miscellaneous Professional Liability APPLICATION Lawyers/Attorneys (Risk Placement Services, Inc.) PDF form

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Miscellaneous Professional Liability

APPLICATION – Lawyers/Attorneys

THIS APPLICATION IS FOR A COVERAGE PART WRITTEN ON A CLAIMS-MADE BASIS.

"CLAIMS" MUST BE FIRST MADE AGAINST ANY INSURED DURING THE "POLICY

PERIOD" OR ANY APPLICABLE EXTENDED REPORTING PERIOD, AND REPORTED TO

US AS SOON AS PRACTICABLE DURING THE "POLICY PERIOD", ANY SUBSEQUENT

RENEWAL OF THE POLICY OR ANY APPLICABLE EXTENDED REPORTING PERIOD. THE

INSURANCE FOR WHICH THIS APPLICATION IS MADE APPLIES ONLY IF THE "WRONGFUL

ACT" OUT OF WHICH THE "CLAIM" AROSE OCCURRED ON OR AFTER THE RETROACTIVE

DATE, IF ANY, SHOWN IN THE DECLARATIONS AND BEFORE THE END OF THE "POLICY

PERIOD". "DEFENSE EXPENSES" ARE PAYABLE WITHIN, NOT IN ADDITION TO, THE LIMIT OF

LIABILITY.

INSTRUCTIONS: Please complete the entire form. If there is insufficient space to complete an answer, please continue

on a separate sheet indicating the question number. If a section does not apply or is not relevant, answer “N/A” or “none”.

Information provided by you will be used by underwriters in determining the acceptability of adding the professionals to

the Miscellaneous Professional insurance coverage.

1. Applicant/Organization Name_____________________________________________________________________

2. Address of Organization_________________________________________________________________________

3. Address where specified professional(s) is located____________________________________________________

4. Type of entity:

Non Profit For Profit Other, Please describe:_____________________________________

5. What is the professionals working relationship with the Applicant/Organization?

Employee Volunteer Contractor

6. Are the Professionals requesting coverage: Full Time Part time If Part Time, How many Hours per week do

they work on behalf of the Organization? __________ How many weeks per year? __________

7. General description of the business of the organization._______________________________________________

___________________________________________________________________________________________

8. List the responsibilities/duties performed for the Organization (please be specific).

____________________________________________________________________________________________

9. Is any Employed lawyer a member of the American Corporate Counsel Association(ACCA)?

Yes No

10. Please attach a separate page providing the following information for each Employed Lawyer to be insured: Name,

title, ACCA membership #(if applicable), year of admission to bar, principal area(s) of practice, and whether the

lawyer is a director or officer of the Organization.

11. Do you or will you perform any of the following services on behalf of the Organization?

Organization Internal Business Services for Others

Contract Drafting/Review/Approval Yes No Yes No

Yes No Yes No

Collection/Repossession

Yes No Yes No

Corporate Transactional

Yes No Yes No

Environmental Compliance

Yes No Yes No

ERISA/Employee Benefits

Yes No Yes No

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International Law Yes No Yes No

Labor Relations

Yes No Yes No

Litigation

Yes No Yes No

Other Regulatory Compliance

Yes No Yes No

Moonlighting(representation of clients other than

Insured Organization)

Yes No Yes No

Pro Bono

Yes No Yes No

Real Estate

Yes No Yes No

Securities

Yes No Yes No

Taxation

Yes No Yes No

Utility Regulation

Yes No Yes No

Other(please describe):_______________________________________________________

12. Does any Employed Lawyer issue written legal opinions to or for the use of:

a) The Board of Directors? Yes No

b) Entities other than the Insured Organization in which the Insured Organization

has an equity interest?

Yes No

c) Third Parties?

Yes No

d) Other?_____________________________

Yes No

If yes to any part of this question, please describe the types of opinions issued and the recipients thereof:______

__________________________________________________________________________________________

13. If litigation is performed on behalf of organization members or clients, or other lawyer clients, indicate the following:

Representing Plaintiff _________% Representing Defense _________%

Average Case size:________________________ Average Case size:________________________

Largest Case size: ________________________ Largest Case size: ________________________

Personal Injury/Bodily Injury _______% Personal Injury/Bodily Injury _______%

Workers Compensation___________% Workers Compensation___________%

Class Action____________________% Class Action____________________%

Medical Malpractice______________% Medical Malpractice______________%

Contractual_____________________% Contractual_____________________%

Business Transaction_____________% Business Transaction_____________%

Other:_________________________% Other:_________________________%

14. Does any Employed or contracted lawyer prepare, review, comment on, or approve financial statements, proxy

statements, prospectuses, registration statements, annual or quarterly reports, or other reports filed with federal or

state agencies or released to shareholders or the public regarding the Organization?

Yes No

If yes, please describe the role of Lawyer(s) in such preparation, review, comment or approval._____________

________________________________________________________________________________________

15. Does any Employed or contracted lawyers represent individual employees of the Organization in judicial,

administrative, or other proceedings?

Yes No If yes, please provide details:_______________________

________________________________________________________________________________________

16. Does any employed or contracted lawyer provide personal legal services to any director, officer, or employee of the

Organization in such director’s, officer’s or employee’s individual capacity?

Yes No If yes, please indicate:

a) The type of personal legal services provided:_______________________________________________

___________________________________________________________________________________

b) The percentage of the Lawyer’s time devoted to the provision of personal legal services:_____________

17. Please provide a brief description of the structure and management of the legal department, including the legal

department’s placement within the general organization of the Insured Organization.

__________________________________________________________________________________________

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__________________________________________________________________________________________

18. Please indicate the types of legal work that are typically referred by the Organization to outside counsel and any

guidelines governing such referrals. _____________________________________________________________

__________________________________________________________________________________________

19. Do you provide any other professional services on behalf of the Organization?

Yes No

If yes, please describe below:

____________________________________________________________________________________________

20. Does the organization have an indemnification policy or practice applicable to Employed Lawyers, regardless of

whether the Employed Lawyers are directors or officers of the organization?

Yes No

If yes, please provide details and attach indemnification provisions and relevant limitation of liability provisions in the

certificate of incorporation or corporate bylaws, as well as any other indemnification policies or agreements.

____________________________________________________________________________________________

21. Does the organization and/or the legal department have written policies or procedures with regard to the following:

Training of newly hired employed lawyers?

Yes No

Continuing legal education for employed lawyers?

Yes No

Circulation and updating of documents within legal department?

Yes No

Litigation docket control within the legal department?

Yes No

Preparation and approval of legal opinions for the use of entities

other than the organization? Yes No

Organization compliance with federal, state, or local statutes or

regulations? Yes No

Employee hiring, termination, and promotion?

Yes No

22. How do the employed lawyers avoid conflicts of interest? Is a conflicts avoidance system utilized?_____________

___________________________________________________________________________________________

23. Specifically, what procedures are in place to:

a) Avoid conflicts between employed lawyers duties to the Organization and any legal services provided to

Directors, Officers, or Employees?_____________________________________________________________

________________________________________________________________________________________

b) Avoid conflicts between employed lawyers duties to the Organization and any legal services provided to

members and clients of the organization?________________________________________________________

_________________________________________________________________________________________

24. Is the professional applicant controlled, owned or associated with any other firm, corporation or company, other than

as stated above?

Yes No If yes, please provide full details:____________________________________

_________________________________________________________________________________________

25. Have all known potential claims, incidents or suits, if any, been reported to your present carrier?

Yes No

26. Has the applicant, predecessors or any other person for whom insurance is being requested ever been subject of a

reprimand or disciplined by, or refused admission to, a bar association, court or administrative agency?

Yes No If yes, please provide full details:__________________________________________________

_________________________________________________________________________________________

27. After inquiry, have any claims or suits been made against any employed lawyer within the past five(5) years arising

out of his or her provision of legal services, whether or not such claims or suits arose out of work performed for the

Organization?

Yes No If yes, please provide a complete Claim Summary for each such claim or suit.

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28. After inquiry, is any lawyer seeking coverage aware of any circumstance, allegation, or contention as to any incident

which may result in a claim or suit against any Lawyer seeking coverage?

Yes No If yes, please provide a

complete Claim Summary for each such circumstance, allegation, or contention.

Note: Information provided in response to Questions 19 and 20 does not constitute notice of a claim or potential

claim under any insurance policy. All such notices must be submitted in accordance with the policy.

29. Have you ever been convicted of a crime or felony?

Yes No

30. Provide information on your in-force professional Liability insurance. (if none exists, please indicate “none”)

a) Insurance Company Name ________________________________Expiration date _________________

b) Limits of Liability $______________________________________Policy # ______________________

c) Does your policy cover you while performing work for the agency/organization? Yes___ No___

d) Retroactive Date _______________________________________

NOTICE TO APPLICANT – PLEASE READ CAREFULLY

FOR THE PURPOSE OF THIS APPLICATION, THE UNDERSIGNED, AS AUTHORIZED AGENT FOR ALL

PERSONS AND ENTITIES PROPOSED FOR THIS INSURANCE, DECLARES THAT TO THE BEST OF

HIS/HER KNOWLEDGE THE STATEMENTS HEREIN ARE TRUE AND COMPLETE. THE INSURER IS

AUTHORIZED TO MAKE ANY INQUIRY IN CONNECTION WITH THIS APPLICATION. SIGNING THIS

APPLICATION DOES NOT BIND THE INSURER TO ISSUE, OR THE APPLICANT TO PURCHASE, ANY

INSURANCE POLICY.

THE INFORMATION CONTAINED IN AND SUBMITTED WITH THIS APPLICATION IS ON FILE WITH THE

INSURER. IF THE INFORMATION IN THIS APPLICATION MATERIALLY CHANGES PRIOR TO THE

EFFECTIVE DATE OF THE POLICY, THE APPLICANT MUST NOTIFY THE INSURER, WHO MAY MODIFY

OR WITHDRAW THE QUOTATION.

THE UNDERSIGNED DECLARES THAT THE INDIVIDUALS AND ORGANIZATIONS PROPOSED FOR THIS

INSURANCE HAVE BEEN NOTIFIED THAT:

A. THIS POLICY APPLIES ONLY TO "CLAIMS" FIRST MADE OR DEEMED MADE AGAINST THE

INSUREDS DURING THE "POLICY PERIOD" OR EXTENDED REPORTING PERIOD, IF EXERCISED;

AND

B. THE LIMIT OF LIABILITY IS REDUCED BY AMOUNTS INCURRED AS "DEFENSE EXPENSES" AND

SUCH EXPENSES WILL BE SUBJECT TO THE DEDUCTIBLE AMOUNT.

(WORDS WITHIN QUOTATION MARKS ARE DEFINED IN THE INSURANCE POLICY.)

FRAUD STATEMENT

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.

FRAUD STATEMENT 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.

FRAUD STATEMENT TO ARKANSAS 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.

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FRAUD STATEMENT 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

claimant with regard to settlement or award payable from insurance proceeds shall be reported to the

Colorado division of insurance within the department of regulatory agencies.

FRAUD STATEMENT 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.

FRAUD STATEMENT 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 of the

third degree.

FRAUD STATEMENT 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.

FRAUD STATEMENT 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.

FRAUD STATEMENT 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 a denial of insurance

benefits.

FRAUD STATEMENT TO MARYLAND APPLICANTS

Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit

or who knowingly and willfully presents false information in an application for insurance is guilty of a crime

and may be subject to fines and confinement in prison.

FRAUD STATEMENT 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.

FRAUD STATEMENT 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.

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FRAUD STATEMENT 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.

FRAUD STATEMENT 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.

FRAUD STATEMENT 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.

FRAUD STATEMENT TO OREGON APPLICANTS

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or

knowingly presents materially false information in an application for insurance may be guilty of a crime and

may be subject to fines and confinement in prison.

FRAUD STATEMENT 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.

FRAUD STATEMENT TO RHODE ISLAND 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, including failing to disclose whether

the applicant or applicants have been convicted of any degree of the crime of arson, is guilty of a crime and

may be subject to fines and confinement in prison.

FRAUD STATEMENT 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.

FRAUD STATEMENT TO VERMONT 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 may be a crime and subjects such person to criminal and civil penalties.

FRAUD STATEMENT 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.

FRAUD STATEMENT TO 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 include imprisonment, fines and denial of insurance

benefits.

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FRAUD STATEMENT TO 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.

______________________________________________ _______/_______/_______

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