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1 APPLICATION FOR PRIVATE PRACTICE CLAIMS-MADE LAWYERS PROFESSIONAL LIABILITY INSURANCE FIRM INFORMATION 1. Contact Person (please indicate Mr. or Ms): Firm Name: Primary Office Address: City, State, ZIP: Telephone Number: Fax Number: Contact's Address: Policy effective date desired: PRACTICE INFORMATION 2. a. What percent of the applicant's time is spent in the following areas of practice? Round to the nearest whole percent. Arbitration/Mediation Estate Planning/Wills/Probate Real Estate Bankruptcy Immigration Commercial Collections Insurance Defense Residential (1-4 units) Representation of Creditors Intellectual Property: Securities/Bonds Representation of Debtors Patent Other (describe) Corporate/General Business Intellectual Property Litigation (not otherwise specified) Copyright or Trademark Criminal Defense Licensing/Trade Secret Domestic/Family Law Plaintiff: Collaborative Domestic Law Personal Injury Traditional Domestic Law FELA Entertainment/Sports Environmental Employment Law Workers Compensation Social Security Disability Total (must equal 100%) b. In the past 5 years has the applicant firm, or any attorney proposed for this insurance, engaged in any mass tort or class action cases? Do not include cases in which the only involvement was a referral where no fee was or will be retained, and the applicant firm or the attorney performed no work on that matter? Yes No c. Have you or any attorney proposed for this insurance represented any clients with respect to the sale or issuance of debt or equity securities in the past 48 months? * Yes No *Do not include isolated transactions involving only insiders or fewer than 4 persons, such as may occur in the organization of a corporation or limited partnership, where no notice or filing is required with the SEC or state agency. 3. Does 25% or more of the applicant firm s revenue come from referrals to other attorneys or firms? Yes* No * a. If Yes, what percent of the applicant firm s income comes from referrals to other attorneys or firms? % * b. If Yes, is it verified that the other attorneys or firms also carry lawyers professional liability insurance? Yes No 4. Does the applicant firm practice law in a state or country other than the state or country in which the primary office is located? Yes* No * If Yes, please provide the following information for each additional state or country. Estimated Percentage State or Country of Firm s Total Time Type of Practice in the Additional State or Country % % 5. Does the applicant firm or any attorney proposed for this insurance ever hire independent contractor attorneys to provide services for the applicant firm s clients? Yes* No * If Yes, please answer the following questions: a. Does the applicant firm verify that all independent contractor attorneys carry professional liability insurance or are the independent contractor attorneys listed on the applicant firm s Schedule of Attorneys? Yes No b. Do any independent contractor attorneys have client contact? Yes No c. Do any independent contractor attorneys sign documents or make appearances on behalf of the applicant firm as an attorney? Yes No d. Are any independent contractor attorneys represented to the public as being a member of your firm? Yes No MDM-1 Net (07-06) Page 1 of 8

2 6. Does any attorney proposed for this insurance ever act as an independent contractor performing legal services on behalf of any other attorneys or firms? (Do not include co-counsel or referral arrangements.) Yes* No * If Yes, please answer the following questions: a. What percentage of the applicant attorney s time is spent doing work on behalf of other firms? % b. Does the applicant firm verify that the other firms also carry lawyers professional liability insurance? Yes No c. Does the applicant attorney have contact with the other firm s clients? Yes No d. Does the applicant attorney sign documents or make appearances on behalf of the other firm? Yes No e. Does the applicant attorney represent to the public as being a member of the other firm? Yes No f. Is the applicant attorney listed on the other firm s letterhead? Yes No 7. Does 100% of the applicant firm's income come from one client? Yes* No * If yes, please describe: 8. Outside Interests/Conflicts: a. In the past 5 years, has any attorney proposed for this insurance engaged in any business other than the practice of law while also practicing law? (Do not include "teaching", "property leasing" or "farming") Yes* No * If yes, please describe: b. Does the applicant firm or any attorney proposed for this insurance serve the firm s clients in another professional capacity? (e.g., as CPA, broker, agent, tax preparer, etc.)? Yes* No * If yes, please describe: c. Is any attorney of the applicant firm an officer or director of any client entity? Yes* No * If yes, do all of these clients have Directors & Officers insurance with limits at least as high as the applicant s lawyers professional liability policy? Yes No d. Does the applicant firm and any of its attorneys collectively have 10% or more equity interest in any client? Yes* No * If yes, was such interest taken in lieu of fees? Yes No e. Does the applicant firm or any attorney have any equity interest in the following types of businesses? Yes* No Banking/financial institutions Yes* No Mortgage, real estate, or securities broker Yes* No Real Estate development clients Yes* No Investment/financial clients Yes* No Consultants (Business Consultants or other) Yes No Title Agency * If the answers to any of these questions is yes, please advise what steps the applicant firm has taken to avoid an actual or alleged conflicts of interest claim. 9. Does the applicant firm sue for its attorney fees? Yes* No * If Yes, please answer the following questions: a. How many times in the past 5 years has the applicant firm sued for its attorney fees? * * Do not include fee arbitration, mediation or other alternative fee dispute resolution processes. b. Does the applicant firm have a review process before filing a suit for fees wherein the file is reviewed with regard to whether a favorable outcome was obtained for the client and whether the engagement letter and all pertinent documents are in order, etc? Yes No 10. Does any attorney proposed for this insurance, or any other employee of the applicant, have check-signing authority for any of your clients' accounts? Yes* No * If yes, are the accounts reconciled by someone other than the person signing the checks and making the deposits? Yes No CLAIMS, POTENTIAL CLAIMS AND DISCIPLINE NOTE: SHOULD A POLICY BE ISSUED, ANY CLAIM OR POTENTIAL CLAIM OF WHICH ANY FIRM MEMBER HAS KNOWLEDGE (WHETHER OR NOT IT IS REPORTED TO US) WILL NOT BE COVERED UNDER THIS OR ANY SUBSEQUENT POLICY. THIS APPLIES WHETHER OR NOT WE ATTACH A SPECIFIC EXCLUSION REGARDING SUCH CLAIM OR POTENTIAL CLAIM. A CLAIM IS A DEMAND OR SUIT COMMUNICATED TO THE INSURED FOR DAMAGES OR PROFESSIONAL SERVICES; A LAWSUIT SERVED UPON THE INSURED SEEKING DAMAGES; OR AN ACT, ERROR OR OMISSION BY ANY INSURED WHICH HAS NOT RESULTED IN A DEMAND FOR DAMAGES BUT WHICH AN INSURED KNOWS OR REASONABLY SHOULD KNOW, WOULD SUPPORT SUCH A DEMAND. SEE THE POLICY FOR THE EXACT WORDING. 11. Have any claims been reported, (whether pending, closed or settled) against the applicant or the applicant's predecessors in business, or any past or present firm members or employees within the past 5 years? Yes* No 12. Is any firm member aware of any INCIDENT (whether previously reported or not), which COULD REASONABLY result in a claim being made against the applicant, its predecessors or any past or present firm members? The answer should include meritless cases and claims currently not in suit. Yes* No *If yes to 11 or 12, give full details on the attached Supplemental Claim Application and provide copies of all relevant documents. 13. Has any attorney proposed for this insurance been disciplined publicly or privately for an ethics violation or does any attorney proposed for this insurance have any pending ethics complaints? Yes* No * If yes, please fax us a copy of all relevant documents. ( ) MDM-1 Net (07-06) Page 2 of 8

3 14. Has the applicant firm or any attorney proposed for this insurance ever purchased an extended reporting endorsement from any previous carrier? Yes* No * If yes, please fax us a copy of the endorsement. ( ) QUOTATIONS REQUESTED/INSURANCE HISTORY LIMITS AND DEDUCTIBLES ARE SUBJECT TO UNDERWRITING APPROVAL. ALL LIMITS AND DEDUCTIBLES MAY NOT BE AVAILABLE. IF TERMS ARE OFFERED, REVIEW THE LIMTS AND DEDUCTIBLES CLOSELY. 15. Limits of Liability (includes claim expenses) Per Claim/Aggregate Per Claim/Aggregate Per Claim/Aggregate Per Claim/Aggregate Per Claim/Aggregate 100,000/300, ,000/900,000 1,000,000/3,000,000 3,000,000/5,000,000 5,000,000/5,000, ,000/600, ,000/1,000,000 2,000,000/5,000,000 4,000,000/5,000,000 Other 16. Deductible Per Claim Minimum by Size of Firm (If a deductible of interest is not offered please contact a representative) Sole Practitioner $1, $ 5, $15,000 Higher (specify) 2-3 attorneys $2, $10, or more $25,000 $ 17. Is the applicant firm currently insured? Yes* No * If Yes, please provide: Current Carrier Limits Deductible Expiration Date (mo/day/yr) $ $ 18. In the past 10 years, has any similar insurance for the applicant, its predecessors or any attorney proposed for this insurance ever been declined, non-renewed or canceled by an insurance company? Yes* No * If Yes, please provide details. Include copies of any notices from prior carrier(s). After you read this section, you will be asked to certify that a reasonable inquiry has been made within the firm to obtain confirmation that the answers contained herein are true, correct and complete to the best of your knowledge and belief, and that the information contained in the application, supplements, attachments and statements are true, and that no facts have been suppressed or misstated. You are also confirming the fact that this application is being submitted by an authorized representative of the law firm. BY THE ACT OF ENTERING THIS INFORMATION AND SUBMITTING THIS APPLICATION, THE SUBMITTING PARTY IS SIGNING THIS APPLICATION. ALL RIGHTS AND RESPONSIBILITIES ACCORDED A PHYSICAL SIGNATURE WILL BE CONSIDERED TO HOLD. THE SUBMISSION OF THIS APPLICATION DOES NOT BIND LEGAL MUTUAL LIABILITY INSURANCE SOCIETY OF MARYLAND (THE COMPANY) TO ISSUE A POLICY OR THE APPLICANT TO PURCHASE THE INSURANCE. If The Company accepts this application by issuing a policy, this application shall be the basis of the policy of insurance and incorporated therein. It is agreed and understood that the applicant has a continuing obligation to report to The Company, as soon as possible, any material changes in the circumstances of the applicant s practice of law, including, but not limited to, the size of the firm and any changes in the information contained in the applications, supplements, attachments and statements submitted herewith. By signing this application you agree that we may contact you via telephone, fax, or other method to discuss your insurance coverage and other products or services offered by Legal Mutual Liability Insurance Society of Maryland or any of its affiliates. The applicant authorizes the release of claim information from any prior insurer to The Company. The applicant hereby certifies all known claims and all known incidents which might become a claim have been reported to the present or previous insurance carriers and the applicant has no knowledge of any threatened litigation or existing fact or situation which could result in a claim being filed against the applicant. Failure by the applicant to report any known claim, or any known facts which may result in a claim, to current or previous insurers may result in the declination of coverage for these matters by current or previous insurers. 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. Return this application to: Legal Mutual Liability Insurance Society of Maryland 333 South Seventh Street Suite 2200 Minneapolis, MN Signature of Owner Partner or Authorized Officer Title Date MDM-1 Net (07-06) Page 3 of 8

4 Firm Name OFFICE SYSTEMS SUPPLEMENT Please answer all questions completely. The answers may affect your eligibility for certain programs. 1. Does any attorney in your firm handle litigation? Yes No 2. Check ALL the following areas that apply to the firm's diary, calendar or docket controls: a. The firm has a centralized calendar for diary/docket control that is backed up regularly. b. The attorney uses a dual calendar system that includes use of (or access to) the centralized system. c. The control(s) is/are maintained by 2 or more individuals and cross-checked weekly or more frequently. d. No diary, calendar or docket controls are used. e. The firm uses a docket, calendar or diary software program designed for attorneys. 3. Check ALL the following areas that are part of the firm's diary, calendar or docket controls: a. Jurisdictional, statutory or other legal deadlines (statutes of limitation, notice provisions, expert affidavits, summons, etc.) b. Dates for court hearings, trial dates, appearances, depositions, administrative hearings/appearances, mediations/arbitrations, closings, conferences, or any kind of other appearances where a client s rights might be at stake. c. Dates for filings, appointments, commitments to clients, and other important deadlines relevant to your practice. d. The calendar system has a perpetual reminder for confirming completion of events. e. Dates for document preparation and research. f. None of the above. 4. Check ALL the following areas that apply to the firm's written (i.e. card file index or list) OR computerized conflict of interest system: a. Existing client names are listed. b. Former client names are listed. c. Declined clients names are listed (clients that have been declined after discussing the case). d. Adverse, opposing and other related parties involved in matters or who have disclosed confidential information are listed. e. Names are checked against the written OR computerized conflict of interest system before files are opened. f. No written OR computerized conflict of interest system is in place. g. The firm uses a conflict software program designed for attorneys. 5. In matters of client communication, check ALL the following that apply: a. Written fee/retainer agreements or engagement letters documenting the scope of representation are used in nearly all matters. b. New client intake forms are used. c. New client intake forms include deadline dates. d. After discussing the case and if the firm chooses not to provide representation, the firm promptly declines or withdraws in writing. e. Settlement offers and closed matters are documented in writing. f. The office policy is to contact active clients at regular intervals. g. The office policy is the attorney, or staff if attorney is unavailable, is to return client phone calls within 24 hours. h. None of the above. 6. If the applicant is a sole practitioner, have arrangements been made for a back-up attorney or are procedures in place for a trained individual to notify clients in case of an unexpected absence? Yes No NA (Continued) MDM-1 Net (07-06) Page 4 of 8 Legal Mutual Liability Insurance Society of Maryland 333 S. 7th St, Suite 2200; Minneapolis, MN phone fax

5 OFFICE SYSTEMS SUPPLEMENT (Continued) Please answer all questions completely. The answers may affect your eligibility for certain programs Only answer this part of question 7 if you have associates in your firm: Describe associate supervision and review techniques. Check ALL the following that apply: a. General firm meetings. b. Regularly scheduled associate review meetings. c. The firm has open door policy for associates to ask questions. d. Experienced attorneys are specifically assigned to mentor associates. e. Matters are discussed at time of annual associate review. f. Individual formal file review. g. None of the above Only answer this part of question 7 if there are partners, multiple owners in the firm or the firm uses independent contractors: Check ALL the following that apply for peer review: a. Regularly scheduled meetings. b. Informal discussion of cases and workload. c. Individual formal file review. d. None of the above. Complete Questions 8-13 only if 35% or more of the firm's practice is PLAINTIFF Personal Injury, FELA, Workers Compensation, Social Security Disability or Employment Law. 8. Is there a centralized diary, calendar or docket control used by all attorneys in the firm? Yes No 9. Check ALL appropriate responses: a. The firm has a written workflow procedure for calendaring. b. An individual in the firm is assigned calendaring responsibility. c. The firm uses two separate diary, calendar or docket controls on which all items are entered. d. The control(s) is/ are maintained by two individuals or more and cross-checked weekly or more frequently. e. Time deadlines are noted on file folders or jackets. f. The firm uses a docket/diary software program designed for attorneys. g. None of the above. 10. Are the appropriate statutes of limitation and notice provision dates (for all applicable jurisdictions) determined and verified by an attorney as part of the file opening process? Yes No 11. Check ALL the following areas that are part of the firm's diary, calendar or docket control: a. All jurisdictional deadlines (including statute of limitation, notice provisions, expert affidavits, summons, etc.) b. Dates for court hearings, appearances and depositions. c. Dates for responsive pleadings and briefs. d. All discovery deadlines. e. All court-ordered deadlines. f. Allocates required time for trial preparation. g. None of the above. 12 Does the firm use a "tickler" or diary system to give advance notice of upcoming deadlines? Yes No 13. How often are reviews of each open file or case conducted by the responsible attorney? Please check ONE of the following : a. Quarterly or more frequently. b. Semi-Annually. c. Yearly. d. Intermittent with no set schedule. e. Never. MDM-1 Net (07-06) Page 5 of 8

6 SCHEDULE OF ATTORNEYS (Including Sole Practitioner) A. List all attorneys employed by or working on behalf of the firm. If sole practitioner, list yourself. If not enough room to list all attorneys, copy this and use as many additional forms as necessary. Please review the Attorney Status options below, including the definitions for OF COUNSEL and INDEPENDENT CONTRACTOR. Attorney Status: O = Owner P = Partner A = Associate/Employee C = Of Counsel 1 I = Independent Contractor 2 1 Legal Mutual Liability Insurance Society of Maryland defines an Of Counsel as an attorney in an advisory position with no client contact. Coverage is intended for the retired attorney that acts in an advisory capacity only and has no client contact. 2 Legal Mutual Liability Insurance Society of Maryland defines an "Independent Contractor" as an attorney who is not an employee of your firm, who you hire to perform legal services on behalf of your clients. This does not include a co-counsel or referral arrangement. Note: Coverage for an "Of Counsel" or "Independent Contractor" is only for services performed on behalf of the applicant firm. 1. Name (First, MI & Last) Status (see above) Address Attorney ID or Social Security Number No. of yrs in practice If the above attorney is an Owner (O), Partner (P) or Associate (A) complete question a. a. Is this attorney currently insured? Yes* No *If Yes, does this attorney have a specific prior acts retroactive date on the applicant firm s current policy? Yes 1 No 2 1 If Yes, what is his or her retroactive date? (mo/day/yr): 2 If No, is this attorney covered under your current policy for work done at previous firms? Yes 3 No 4 3 If Yes, provide the date this attorney entered private practice (mo/yr): 4 If No, provide the date this attorney joined the applicant firm (mo/day/yr): If the above attorney is an Of Counsel (C), complete question b. b. (1) Please provide the date this attorney first provided legal services for the applicant firm. (mo/day/yr): (2) Does the attorney work in an advisory position only? Yes No (3) Does the attorney have client contact? Yes No (4) Does the attorney engage in any private practice of law outside of the applicant firm? Yes No (5) Is this attorney currently insured under the applicant firm's policy? Yes 1 No 1 If Yes, has this attorney been continuously insured under the applicant firm's policy since first performing legal services on the applicant firm s behalf? Yes No 2 2 If No, what is the first date of continuous insurance under the applicant firm s policy for services performed on the applicant firm s behalf? (mo/day/yr): If the above attorney is an Independent Contractor (I), complete question c. c. (1) Please provide the date this attorney first provided legal services for the applicant firm. (mo/day/yr): (2) Is this attorney currently insured under the applicant firm's policy? Yes 1 No 1 If Yes, has this attorney been continuously insured under the applicant firm's policy since first performing legal services on the applicant firm s behalf? Yes No 2 2 If No, what is the first date of continuous insurance under the applicant firm s policy for services performed on the applicant firm s behalf? (mo/day/yr): MDM-1 Net (07-06) Page 6 of 8

7 2. Name (First, MI & Last) Status (see above) Address Attorney ID or Social Security Number No. of yrs in practice If the above attorney is an Owner (O), Partner (P) or Associate (A) complete question a. a. Is this attorney currently insured? Yes* No *If Yes, does this attorney have a specific prior acts retroactive date on the applicant firm s current policy? Yes 1 No 2 1 If Yes, what is his or her retroactive date? (mo/day/yr): 2 If No, is this attorney covered under your current policy for work done at previous firms? Yes 3 No 4 3 If Yes, provide the date this attorney entered private practice (mo/yr): 4 If No, provide the date this attorney joined the applicant firm (mo/day/yr): If the above attorney is an Of Counsel (C), complete question b. b. (1) Please provide the date this attorney first provided legal services for the applicant firm. (mo/day/yr): (2) Does the attorney work in an advisory position only? Yes No (3) Does the attorney have client contact? Yes No (4) Does the attorney engage in any private practice of law outside of the applicant firm? Yes No (5) Is this attorney currently insured under the applicant firm's policy? Yes 1 No 1 If Yes, has this attorney been continuously insured under the applicant firm's policy since first performing legal services on the applicant firm s behalf? Yes No 2 2 If No, what is the first date of continuous insurance under the applicant firm s policy for services performed on the applicant firm s behalf? (mo/day/yr): If the above attorney is an Independent Contractor (I), complete question c. c. (1) Please provide the date this attorney first provided legal services for the applicant firm. (mo/day/yr): (2) Is this attorney currently insured under the applicant firm's policy? Yes 1 No 1 If Yes, has this attorney been continuously insured under the applicant firm's policy since first performing legal services on the applicant firm s behalf? Yes No 2 2 If No, what is the first date of continuous insurance under the applicant firm s policy for services performed on the applicant firm s behalf? (mo/day/yr): B. Does any attorney consistently practice less than full time? Yes* No *If Yes, please provide the attorney s name and number of hours worked per month. C. Is any attorney also an employee of anyone other than the applicant firm? Yes* No *If Yes, please provide the attorney s name and provide details including a description of the other employment. D. Does any attorney spend 25% or more of his or her time as a city or county attorney? Yes* No *If Yes, please designate which attorney(s) *Is coverage desired for this work? Yes No E. Does any attorney spend 25% or more of his or her time as a Public Defender? Yes* No *If Yes, please designate which attorney(s) *Is coverage desired for this work? Yes No F. Are there any practicing attorneys listed on the applicant s letterhead who are not on the above schedule of attorneys? Yes* No *If Yes, please provide the attorney s name. MDM-1 Net (07-06) Page 7 of 8

8 SUPPLEMENTAL CLAIM APPLICATION APPLICANT'S INSTRUCTIONS: A. To be completed by any applicant who has been involved in a claim or suit or is aware of an incident which may give rise to a claim. Include meritless claims and claims currently not in suit. B. COMPLETE ONE FORM FOR EACH CLAIM OR INCIDENT. C. Sign at the bottom of the form and return to: Legal Mutual Liability Insurance Society of Maryland; 333 S. 7 th St, Ste 2200; Minneapolis, MN 55402; (800) (fax) NOTE: SHOULD A POLICY BE ISSUED, ANY CLAIM OR POTENTIAL CLAIM OF WHICH ANY FIRM MEMBER HAS KNOWLEDGE (WHETHER OR NOT IT IS REPORTED TO US) WILL NOT BE COVERED UNDER THIS OR ANY SUBSEQUENT POLICY. THIS APPLIES WHETHER OR NOT WE ATTACH A SPECIFIC EXCLUSION REGARDING SUCH CLAIM OR POTENTIAL CLAIM. 1. Full name of individual(s) of firm involved in the claim: 2. Full name of claimant: 3. Date of alleged error (mo/yr): 4. Please provide date the claim/incident was reported to your insurer, (mo/yr): 5. If the claim was not covered or has not yet been reported *, the date you first became aware of it (mo/yr): * If you have not yet reported the claim, please report it immediately to your current insurer. 6. Present status of claim: Open 1 In suit 1 ; Closed 2 1 If in suit, or open provide amount of reserves for: a. Indemnity $ *; b. Defense Expenses $ * 2 If closed, provide amount paid: a. to plaintiff for Indemnity $ *; b. Defense Expenses $ * * If unknown, a carrier s loss run report, a statement from defense counsel or agent regarding the values may be submitted. 7. Was this a claim due to a dispute regarding attorney fees? Yes No 8. Name of insurer to whom the claim was reported: 9. If pending, what is your (or defense counsel s) best estimate of the potential damages? $ 10. Defendant's offer for settlement, if any $ 11. Description of case and events, including the allegation upon which Claimant bases the claim: 12. What steps have been taken to avoid similar circumstances from occurring in the future? I/we understand the information submitted herein becomes a part of my/our Professional Liability Policy and is subject to the same representations and conditions. Signature of Owner Partner or Authorized Officer Title Date MDM-1 Net (07-06) Page 8 of 8 Legal Mutual Liability Insurance Society of Maryland 333 S. 7th St, Suite 2200; Minneapolis, MN phone fax