Application for Law Firms – Short Form - Independent Insurance Agents of California

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Application
Professional Liability Insurance for Law Firms
(Short Form)

Notice: Professional liability insurance coverage is provided on a Claims Made basis. Only claims that are first made against the insured and reported to the insurance company during the policy term are covered, subject to the policy provisions. If you want or need additional coverage, a separate application will be required.

Applicant Instructions: Carefully read all statements and questions on this Application. Answer all questions in ink. If a question does not apply, state "N/A". If space is insufficient to answer all questions fully, please use separate sheets of paper. This Application and all attachments must be signed and dated by the named applicant, partner or officer. A copy of your business stationary must be attached.

Effective Date Requested for this Application

Limits of Liability Requested:

Total Desired Deductible:

Per Claim

1.

Name of Applicant (Firm Name):

Name of Designated Contact:

Physical Address:

Telephone Number:

Fax:

Email:

2. Date Firm was Established:

3. Applicant is:

Sole Proprietorship
Professional Corporation
General Partnership
LLP
Other (describe)____________________

4. List all predecessor firms of Applicant. If not applicable, state N/A. A predecessor firm is any legal entity, which is engaged in the practice of law whose assets and liabilities were acquired by the Applicant.

Name of Firm

Date Established

Date of Any Merger

5. List below all attorneys of Applicant. Attach a separate sheet if additional space is required. "O" Owner/Officer/Director "P" Partner "E" Employed Attorney "OC" Of Counsel "IC" Independent Contractor

Name of Attorney and Designation

States of Admission and Years Admitted

Date of hire with Applicant or predecessor firm

Number hours CLE in the past 12 months

6. Complete the following for each Of Counsel, Independent Contractor or Per Diem Attorney.

Name of Attorney

Date of Hire

Hours worked per week for Applicant

Separate Professional Liability Insurance?

Yes
No

Name of Attorney

Date of Hire

Hours worked per week for Applicant

Separate Professional Liability Insurance?

Yes
No

Name of Attorney

Date of Hire

Hours worked per week for Applicant

Separate Professional Liability Insurance?

Yes
No

Name of Attorney

Date of Hire

Hours worked per week for Applicant

Separate Professional Liability Insurance?

Yes
No

Name of Attorney

Date of Hire

Hours worked per week for Applicant

Separate Professional Liability Insurance?

Yes
No

Name of Attorney

Date of Hire

Hours worked per week for Applicant

Separate Professional Liability Insurance?

Yes
No

Name of Attorney

Date of Hire

Hours worked per week for Applicant

Separate Professional Liability Insurance?

Yes
No

Name of Attorney

Date of Hire

Hours worked per week for Applicant

Separate Professional Liability Insurance?

Yes
No

7. Has any attorney proposed for this insurance ever been denied the right to practice, suspended from practice, disbarred, reprimanded or had other disciplinary action taken against him or her by any court or administrative agency?

Yes
No

If Yes, provide details on the Information Addendum.

8. List all Professional Liability Insurance carried during the past consecutive five (5) years for the Applicant and/or any predecessor firm.

If no current coverage is in force, check the box:

No Current Coverage

Policy Inception and Expiration

Insurance Co. and Policy Limits

Deductible and Annual Premium

Number of Attorneys

9. Insurance Details:

Inception date of the Applicant's first continuous claims made professional liability insurance policy:

Does the current policy have a retroactive/prior acts date applicable to Applicant?

Yes
No

Does the current policy have any limiting endorsements or exclusions?

Yes
No

If yes, provide details:

Has the Applicant, its predecessor firms, or any attorney proposed for this insurance, purchased an Extended Reporting Period (ERP) Endorsement?

Yes
No

If Yes, please complete:

Effective from

to

10. Indicate the percentage of the Applicant's income derived from the following types of practice. (Must total 100%)

Type of Practice:

Abstracting / Title

Administrative Law

Admiralty

Adoptions

Ad Valorem Tax – Commercial

Ad Valorem Tax – Commercial

Antitrust Trade Regulations

Arbitrations / Mediations

Banking / Financial Institutions

Bankruptcy

Bonds

Civil Rights / Employment

Class Actions / Mass Tort

Collections – HOA

Commercial Litigation

Construction

Copyrights

Corporate General

Corporation / LLC Formations

Criminal Defense

Divorce

Employment Law

Entertainment

Environment

ERISA

Estate Planning

Family Law (other than Divorce)

Fiduciary

Foreclosures

Health Care

Homeowner Association Law

Immigration

Insurance Company Defense

International Law

Investment Counseling / Money Management

Labor Union Law

Local Goverment / Municipal

Media Law

Medical Malpractice

Mergers / Acquisitions

Oil / Gas

Patents

Personal Injury

Product Liability

Public Utilities

Real Estate - Commercial

Real Estate Development

Real Estate - Residential

Securities - Federal

Securities - State

Social Security

Tax - Individual Preparation

Tax - Business Preparation

Tax - Opinions

Trademarks

Water Law

Workers' Compensation

Total:

P

D

Provide additional information on the Information Addendum if needed.

11. Applicants Gross Revenue for the past three (3) years:

Most Recent Twelve (12) Months

One (1) Year Prior

Two (2) Years Prior

12. Docket/Diary Control System:

Do you maintain a central docket control system?

Yes
No

Does the Applicant have at least two (2) methods for docket control?

Yes
No

Does the Applicant utilize a computer program for docket control?

Yes
No

Does the ultimate responsibility for docket control, including entry, rest with the handling attorney?

Yes
No

Does the Applicant crosscheck its docket controls?

Yes
No

If Yes, how frequently?

If No, provide details on the Information Addendum.

13. How many suits for fees were initiated by the Applicant against clients during the past 24 months?

How many have been resolved?

What percentage of fees are more than 90 days past due?

How frequently are invoices provided to clients?

14. Does the Applicant utilize the following for ALL clients?

Engagement letters that include the scope of services and fee arrangements?

Yes
No

Non-engagement / declination letters?

Yes
No

Disengagement / closing letters?

Yes
No

If No, provide details on the Information Addendum.

15. Does the Applicant maintain a conflict of interest avoidance system?

Yes
No

If No, provide details on the Information Addendum.

Systems used to check conflicts of interest:

How frequently are checks made for conflicts of interest?

How are conflict of interest situations addressed and disclosed to clients/potential clients? Check all that apply.

Non-engagement letters
Signed Waiver Obtained from all parties
Oral Disclosure to all parties
Referral to other attorney /Iaw firm

16. Has any Application for Professional Liability Insurance on behalf of the Applicant, its predecessor firms or any attorneys proposed for this insurance been declined, policy canceled or renewal of such insurance been refused?

Yes
No

If Yes, provide details on the Information Addendum.

17. During the past five (5) years, has any claim or suit been filed against the Applicant, its predecessor firms or any of the attorneys proposed for this insurance?

Yes
No

If Yes to any of the above, complete the Information Addendum.

18. After inquiry, is the Applicant, its predecessor firms or any attorney proposed for this insurance aware of:

Any circumstance, act, error, omission or personal injury which could be the basis of a claim or suit?

Yes
No

Any potential malpractice claim or suit reported to a previous insurance carrier?

Yes
No

Any adverse judgment that could be the basis of a claim or suit?

Yes
No

Any missed statute of limitations?

Yes
No

If Yes to any of the above, complete the Information Addendum.

Signature of Partner, Officer or Owner

Clear Signature

Date

Print or Type Name

Title

Firm Name

CAInsuranceAgents.com

818-658-1500

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