Attorneys Professional Liability insurance

1.  Name*:

2.  Mailing address of principal office:

3.  E-mail*:

4.  Telephone*:

5.  The firm was established on:

6.  (a)  During the past five years, has the firm acquired or merged with another law firm?  
          Yes   No

     (b)  Are there name changes of the current firm, or any predecessor firms, or those referenced in 
            question 4(a), for whom coverage is requested?  Yes  No  
  If the answer to question 4(a) or 4(b) is "Yes", complete Supplement 1, Part B.

7.  Do you have any branch offices?   Yes  No  
  If the answer is "Yes", complete Supplement 1, Part C.

8.  Provide the total number of personnel for all offices:

9.  During the past three years, has the firm or any predecessor closed a branch office or had a group departure of 10% or more of its lawyers?  Yes   No

10.  Provide the gross billings for the complete fiscal year (gross billings means all sums billed to clients for services rendered during the last year):

11.  Provide total lawyer's hours worked on client matters:

12.  (a)  For each policy year, provide the percentage of hours worked on client matters:

(b)  In the past two years, have there been any changes of greater than five percentage points in any of the above?
       Yes  No

If "Yes", please provide full details: 

13.  In the past ten years, has any applicant had any financial institution client? 
       Yes  No  If "Yes", complete Supplement 4.

14.  What percentage and dollar amount of the applicant's billings are more than 90 days overdue from the billing date?        %=$

15.     (a)  In the past five years, has any applicant served as director, officer, trustee or partner of any entity which was, at the time of service, a client?
       Yes  No

(b)  In the past five years, has any applicant held an equity or financial interest (other fees for services rendered) in a client?  Yes   No   If question 13(a) or (b) is "Yes", complete Supplement 3.

16.  In the past five years, has any applicant accepted client securities or other forms ofcompensation in lieu of fees? 
       Yes   No

If "Yes", provide full details: 

17.  During the past ten years, has any applicant held title to property on behalf of any client?  
       Yes   No

If "Yes", provide full details: 

18.  Does any applicant share office space with any other lawyer?  Yes No

If "Yes", complete Supplement 8.

19.  In the past three years, has any applicant provided legal services or advice relating to the issuance, offering or sale of exempt securities or of non-exempt securities in registered or non-registered transactions including limited partnerships? 
       Yes   No
  If "Yes", complete Supplement 5.

20.  Management

(a)  Is the firm managed by a management committee?  Yes   No

(b)  How many principals comprise the management committee?  N/A   %

(c)  Does the firm employ an administrator?  Yes  No

(d)  How much of the above person's time is spent as the administrator?  N/A  %

(e)  Does the firm use a review system to evaluate the performance of principals?  Yes   No

21.  Calendar/Docket

(a)  Does the firm maintain a calendaring system and procedure with at least two independent date controls? 
       Yes   No

(b)  Does the firm use calendar/docket control software?  Yes   No

(c)  Does the system produce at least a weekly calendar?  Yes   No

(d)  Does the system cover all aspects of the firm's practice?  Yes   No

(e)  Does the system require lawyers to both calendar and remove from calendar all filing dates?  
       Yes   No

(f)  Are open entries circulated to all lawyers or, if the firm is divided into formal departments, to all lawyers in the appropriate departments?  Yes   No

22.  Training and Supervision

(a)  Does the firm maintain a training program on office and court procedures for new lawyers?  
       Yes   No

(b)  Does the firm maintain a training program on office procedures for non-lawyer employees?  
       Yes   No

(c)  How many lawyers in the firm participated in formal continuing legal education(CLE) programs during the last year?

(d)  Average CLE hours per lawyer during the last year:

(e) Are all associates of the firm under the direct supervision of a principal?  Yes   No

(f)  Are all employees of the firm subject to periodic review?  Yes   No

23.  New Business

(a)  Are new clients subject to approval of the appropriate committee within the firm or at least two principals?
       Yes   No

(b)  Is information as to all new clients made available on at least a weekly basis to all principals of the firm?
       Yes   No

(c)  Does the firm use conflict prevention software?  Yes   No

(d)  Are potential conflicts always referred to an independent conflict partner or committee?  
       Yes   No

(e)  Is it permissible to do any work on a matter prior to receiving clearance from the conflicts check?  
       Yes   No

(f)  Is each new matter assigned to a principal with specific expertise in the matter?  Yes    No

24.  Outside Communications

(a)  For what percentage of cases does the applicant:

     (i)  when accepting a representation, send an engagement letter?  %

     (ii)  when declining a representation, send a non-engagement letter?  %

     (iii)  when ceasing representation, send a disengagement letter?  %

(b)  Must opinion letters be approved by at least two principals of the firm?  Yes   No

(c)  Must letters to auditors be approved by at least two principals of the firm?  Yes   No

25.  Miscellaneous

(a)  Are lawyers allowed to practice law outside the firm?  Yes   No

(b)  Must service on a client's Board of Directors be approved by the appropriate committee
or by at least two principals? Yes   No

(c)  During the past two years, how many suits for collection of fees have been filed by the firm?  
       Yes   No

(d)  Does the firm have a policy to prohibit trading in client securities on the basis of non-public information?
       Yes   No

(e)  Does the firm retain on behalf of firm clients or delegate work outside counsel?  Yes   No

     (i)  Are acceptance letters required when outside counsel is retained or work is delegated?  
        Yes   No

     (ii)  Is a certificate of insurance required from every firm that accepts delegated work?  
        Yes   No

26.  Are two partners' signatures required in the account opening, handling and disbursement of client, third-party and escrow funds?  Yes   No

27.  Are all law firm personnel covered by an employee dishonesty insurance policy?  Yes   No

28.  Are all lawyers required to follow all policies/procedures in 19-25 above?  Yes   No

29.  During the past ten years, has any applicant been refused admission to practice, disbarred or suspended from practice, or reprimanded, sanctioned or disciplined by any court, administrative agency or bar association? 
       Yes  No

30.  (a)  During the past ten years, has any professional liability claim been made against any applicant or any of the past lawyers in the firm?   Yes   No

(b)  Does any applicant know of any act, error, omission or circumstance that could reasonably give rise to a professional liability claim against:  Yes No

     (i)  the firm?  Yes  No

     (ii)  any predecessor in business listed in Supplement 1, Part B?  Yes  No

     (iii)  any of the past or present lawyers in the firm?  Yes   No

(c)  Have all of the matters shown in (a) and (b) been reported to be the firm's current or former professional liability insurer?  Yes  No 
If question 28(a) or (b) is "Yes", complete Supplement 2 for each claim/incident.

31.  History of Liability Insurance:

(a)  Effective date of the first professional liability policy covering the applicant:

(b)  Has the applicant had continuous claims made coverage since that date?  Yes  No

(c)  Does any applicant have coverage under the extended discovery provisions of any policy?  
     Yes  No

If "Yes", give date of purchase / / and expiration date: / /

(d)  What is the retroactive date shown on the current policy?  Yes   No

(e)  Is the current policy endorsed to expand, limit or exclude coverage?  Yes   No

32.  Has any applicant had their professional liability insurance application declined or their professional liability policy canceled or non-renewed?  Yes  No

If "Yes", provide full details: 

33.  Quotations requested:

LIMITS: 

DEDUCTIBLES:

$1,000,000/$1,000,000

$5,000

$2,000,000/$2,000,000

$10,000

$3,000,000/$3,000,000

$25,000

$4,000,000/$4,000,000

$50,000

$5,000,000/$5,000,000

Colorado - 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 a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

Florida - 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.

Kentucky - 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.

New York - 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.

Ohio - 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.

Oklahoma - Any person who knowingly and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of any insurance policy containing any false, incomplete or misleading information is guilty of a felony.

Pennsylvania - Any person who knowingly and with the intent to defraud any insurance company or other person files an application for insurance or statement of claims 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.

Each supplement, upon completion, becomes a part of this application.

I specifically asked all lawyers in our firm if they have knowledge of any claim or potential claim against us that is not listed in our response to Question 26.  All lawyers responded "No".

If we become aware of any claim or potential claim against us, before the inception of coverage, we will immediately inform the Company, Agent or Broker.

On behalf of our firm, I agree that this application, including all attachments and exhibits, is complete and correct to the best of my knowledge and belief.  I understand that this application forms the basis of the contract of insurance, if the Company offers coverage and we accept the Company's offer.  I also understand that completion of this application does not bind the Company, Agent or Broker to provide insurance.

*Use one of these codes to designate the position held by each lawyer.

P - Principal (any partner, officer or owner)

A - Associate practicing for the firm

OC - Of Counsel

E - Employed practicing lawyer (not otherwise designated)

O - Other

Claim  Incident

Name:    Date of Error :

Date Reported to Insurer :

Please Provide the information without regard to insurance or deductible.

1.  Potential/actual claimant(s): 

2.  Individual lawyer(s) and firm(s) involved in the claim or incident: 

Judgement   Total loss paid: $ (expense + indemnity, total paid by insurer & insured)

Settlement  Date closed : 

Alternative dispute resolution   Deductible : 

(b)  If pending:  Amount of damages sought :  $   
     Claimant's last settlement demand :

Insurer's loss reserve :  $   Defendant's settlement offer :

5.  Insurer to whom submitted for coverage : 

6.  Description of claim or incident : 

(a)  Nature of the client's business? 

(b)  Applicable area of practice? 

(c)  Does this claim/incident rise from a fee dispute?  Yes      No

(d)  Description of events leading to claim/incident, including alleged act, error or omission:

7.  Actions taken by firm to prevent recurrence:

Name: 

During the past five years, have the annual billings to any client listed above exceeded 5% of your total annual billings?  Yes  No

If "Yes", please provide full details: 

Name:

Financial institution means any savings and loan, bank, credit union, savings association, building and loan association or other banking institution or any subsidiary or affiliate thereof.

1.  What was the total of the applicant's billings to all financial institutions?

2.  Does the firm have a policy prohibiting any lawyer or their immediate family from holding stock or other financial interest in a financial institution which is also a client of the firm?   Yes   No   In writing

3.  Does the firm have a policy prohibiting any applicant from acting as a director or officer of a financial institution which is also a client of the firm?  Yes   No  In writing

4.  Does the firm have a policy prohibiting:

(a)  The introduction of a client to any other client financial institution as prospective borrowers?  
     Yes   No  In writing

(b)  The subsequent representation of both borrower and lender?  Yes   No  In writing

5.  Are there any exceptions to the policies indicated in your answers to 2,3 or 4 above?  Yes   No

If "Yes", please provide full details:

With respect to legal services rendered during the past ten (10) years, please identify all client financial institutions and provide the following information for each:

1.  Institution: 

2.  Branch(es) represented: 

3.  Main Office: 

4.  Work Performed - Check if any of the following services were performed:

Dates of Service

  General Counsel     From To

  Regulatory Counsel     From To

  SEC Counsel     From To

  Stock Offerings     From To

  Loan Documentation     From To

  Other, please describe     From To

5.  With respect to the above institution, has any lawyer or former lawyer of the applicant firm:

Dates

  had loan commitments in excess of $100,000?    From To

  had loan commitments in excess of $100,000?    From To

  had loan commitments in excess of $100,000?    From To

  been a member of the following internal committees:

  had loan commitments in excess of $100,000?    From To

  had loan commitments in excess of $100,000?    From To

  had loan commitments in excess of $100,000?    From To

  had loan commitments in excess of $100,000?    From To

Name: 

Please complete the schedule below for any applicant who provides services related t securities transactions.

1.  Provide the gross billings from securities work for the applicable fiscal year (gross billings means all sum billed to clients for any securities related services rendered during the year):

2.  Does the applicant have written procedures designed to :

(a)  assure that there will be no conflict of interest with other securities clients of the firm?  
     Yes   No

(b)  outline the procedures to be followed by all lawyers in performing the "due diligence" process?  
     Yes   No

(c)  prohibit its lawyers and staff from participating in the securities selling process (including marketing calls or communications with prospective investors)?  Yes   No

(d)  prohibit any securities representation of any company in which an equity interest is held by any lawyer in the firm or their immediate family?  Yes   No

(e)  prohibit the use of the firm's name on any disclosure or registration documents other than in connection with expert opinions?  Yes   No

3.  Does the applicant have written procedures requiring review by another experienced lawyer of:

(a)  all disclosure documents?  Yes   No

(b)  all legal opinions (including tax law, environmental, patent validity, etc.)?  Yes   No

4.  Does the applicant have a written policy prohibiting any lawyer from acting as a director or officer of any securities client of the firm?  Yes   No

5.  Does the applicant have a written policy prohibiting the use of dissemination of "insider information" by any lawyer or employee of the firm?  Yes   No

6.  Are all lawyers in the firm and their immediate families required to disclose to the firm all securities investments in clients of the firm?  Yes   No

7.  For what percentage of securities matters does the applicant:

(a)  when accepting a representation, send an engagement letter?  %

(b)  when declining a representation, send a non-engagement letter?  %

(c)  when ceasing a representation, send a disengagement letter?  %

Proxy contests, tender offers and exchange offers

8.  Has the applicant provided legal services in connection with any proxy contest involving a public company?
       Yes   No

9.  Was the applicant representing the nominees of management or the opposition?

management # of times (past 3 years)

opposition # of times (past 3 years)

10.  Please list representations in the past three years in ALL takeover or merger activities.

Name:

Please provide information regarding the assurance or sale of securities for which the firm rendered legal services on behalf of a client during the past three years, and legal services for which a filing is expected to be made within the next ninety days.  Include filings which were withdrawn after having been filed, offerings which were unsuccessful, and filings made pursuant to an exemption from registration under the Act.

Has any lawyer or their immediate family invested in any of the above of the listed clients or their affiliates? 
       Yes   No

If "Yes", complete Supplement 3

Name: 

Please complete the schedule below for any applicant who provides services related to real estate or environmental transactions.

If real estate law is indicated on the Area of Practice Profile, answer questions 1 -11.  If environmental

1.  Real estate policies and procedures:

(a)  Does the firm undertake the calendaring of matters for clients?  Yes   No

(b)  Does the firm undertake any aspect of the financial or valuation analysis of transactions?  
       Yes   No

(c)  Does the firm undertake responsibility for preparing or reviewing closing calculations or documents?
       Yes   No

(d)  Does the firm undertake examination of titles, legal descriptions or survey matters?  Yes   No

(e)  Does the firm offer advice in environmental matters related to hazardous substances?  
       Yes   No

2.  Does the applicant have written procedure with respect to the issuance of opinions on the following:

(a)  Tax matters  Yes   No

(b)  Land use, zoning and related matters  Yes   No

(c)  Possession of required permits & licenses  Yes   No

(d)  Proper security for loans  Yes   No

(e)  Bankruptcy matters  Yes   No

(f)  Lien validity, priority and perfection  Yes   No

(g)  Foreign matters  Yes   No

(h)  Environmental matters  Yes   No

3.  With regard to real estate development, condominium or subdivision projects, has any applicant within the last five years:

(a)  Been counsel for the developer?  Yes   No

(b)  Rendered any legal opinion?  Yes   No

If the answer to any of the above is "Yes", please provide full details:

4.  In the past five years, has your firm performed legal services pertaining to syndication's, limited partnerships or other real estate investment vehicles?   Yes   No

If "Yes", please complete Securities Supplement 5

5.  In the past five years, have you acted as a title insurance agent?   Yes   No

Real Estate - Environmental Concerns

6.  In the past five years, has any applicant provided legal services which include an evaluation of:

(a)  whether the business or property has or will cause environmental problems?  Yes   No

(b)  whether any property owned, leased, operated or held as security is likely to be contaminated by hazardous substances?  Yes   No

(c)  whether any site owned, leased, operated or held as security is located in or adjacent to ecologically sensitive areas?  Yes   No

(d)  whether any client or any affiliate of any client has ever been fined, penalized, cited or sued for violating any environmental law or regulation?  Yes   No

7.  Does the applicant have a written procedure which requires:

(a)  the investigation of potential environmental risks?  Yes   No

(b)  a through evaluation with the client of the economic impact of known environmental issues?  
       Yes   No

(c)  a discussion with the client of the benefits of further identification or qualification of environmental risks?
       Yes   No

8.  Does the applicant have a written procedure outlining the proper handling of confidential information concerning environmental audits or investigation of parties involved in the transfer of property?  
       Yes   No

9.  Does the applicant have a written procedure requiring the preservation of records concerning disclosure of site contamination to potential buyers or lessees?    Yes   No

If "Yes", how long are the records maintained?

10.  Does the applicant have written procedure which requires its real estate lawyers to participate in educational sessions on current environmental law?    Yes      No

11.  Does the applicant have a written procedure which requires, prior to the selection of environmental consultants, the following:

(a)  the recommendation of at least two consultants so as to require the client to choose one?
       Yes      No

(b)  the generation and preservation of written client communications verifying the client's responsibility for the consultant engagement decision and any resultant risks?    Yes      No

Name: 

1.  Describe the firm's litigation practice:

(a)  What percentage of plaintiff PI suits that you have filed in court were terminated by:

          (i)  Trial/Verdict

          (ii)  Settlement/Award

          (iii)  Other     

         Please explain:

(b)  Describe types of cases handled:

2.  Litigator's Profile:

Name:

1.  If you are currently in an office-sharing or expense-sharing arrangement with another lawyer or firm , provide:

2.  Describe the letterheads used by lawyers or firms identified in 
Question 1.

3.  Do you advertise together?

4.  Do you share staff, i.e., paralegal, legal assistants or receptionists?

If "Yes", please describe:

5.  Do you share a common phone line?

If "Yes", how are the lines answered?