APPLICATION FORM. Professional Indemnity Insurance

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1 APPLICATION FORM Professional Indemnity Insurance Lawyers Instructions to the applicant. A. Please answer all questions. The information is required to make an underwriting and pricing evaluation. Your answers hereunder are considered legally material to that evaluation. B. If a question is not applicable, state N/A. If more space is required to answer a question please attach exhibit with question number. C. A principal of the Firm must sign and date this form and any separate sheet. D. DOCUMENT CHECKLIST This application, fully completed, signed and dated. A sheet of your firm s current Headed tepaper. Fully completed claim forms for all circumstances, incidents or claims reported to other Insurers by your firm and any predecessor firm (prior practice). CV of principals, officers and professional staff The Internal Control and/or Quality Control Procedures Copy of standard contract and engagement/proposal letter used with clients 1

2 Section I The Law Firm 1. Please state the name of the law firm 2. Address, website and address 3. Please state name of all branches to be covered by the insurance. If you have branch offices abroad please provide information whether local policies are in place. 4. The Applicant is: Corporation Partnership Individual Office Sharing Associates Other 5. Date the firm was established 6. List the name of all predecessor firms (prior practice) of Applicant (name only those firms where the Applicant is a successor to the former firm s assets and liabilities). Name of Practice(s), Date of establishment, Date of Succession, Number of Partners, Officers & Directors and Number of employed lawyers 2

3 Have any of the practices above reported any circumstances, incidents or claims in the last five years? If yes, please explain on a separate sheet. 7. Please provide the total number of hours of continuing education completed by all lawyers in your firm over the past twelve (12) months. 8. Does the applicant and/or any lawyer in the firm share office space or staff with any other lawyer or law firm? If yes, please provide information. 9. Does below apply currently to any lawyer in the firm or for legal services rendered by the firm for the past three (3) years? A director or officer to a client? If yes, please complete the supplemental Application. 10. Fees - please state the fees for the last two years 11. Please include a list of the firm s five largest assignments during the past three years Client Name: Activities performed for the client Fees: 3

4 Section II Partners and employees 12. Please state name of all partners and the year the partner commenced to practise law Name Year 4

5 13. Please state the following Number of Partners: Number of lawyers (excluding Partners): Number of associate lawyers: Number of other staff: In which country are the lawyers allowed to practice? Please provide information. Section III Operations 14. Please state percentage () of total income relating to the following areas of practice Work for Banks, Insurance Companies, stockbrokers and other financial institutions Property & Real Estate Mergers & Acquisitions Due Diligence Corporate & Commercial Insolvency/Bankruptcy Criminal law International law Marine law Tax law Labour Relations Domestic Relations and Matrimonial Environmental Litigation Intellectual Property Rights (if more than 5 please provide split below) Public law EC law Other (if more than 10 please provide information below) Total 100 Intellectual Property split Patent Copy Right Trade Mark Other 5

6 If Other above generates more than 10 please provide information Do you provide management services or investment advice to any entertainment clients or sporting professionals? If yes, please explain on a separate sheet. In the last five years, has your firm or any predecessor firm (prior practice) accepted instructions for class actions? If yes, please explain on a separate sheet. 15. Please state percentage () of total income relating to the following types of clients Private Companies Small Companies Midsize Companies Multinationals Government 16. Please answer whether you have clients abroad? Region Number of Clients Fees US/Canada UK Europe (outside of your own country) ROW 17. To what professional association(s) does the applicant belong? 6

7 18. Please state number of cases per year 19. Please state number of clients per year for the last two years 20. Please describe your firm s system to meet deadlines (docket/time control system). 21. How many independent date controls are kept? 22. How often are they crosschecked? Daily Weekly Monthly Other (please describe below) 23. If you are a sole practitioner, please provide the name of the lawyer who would be responsible for your business if you were absent for an extended period. 24. a. Percent of firm s billings more than 90 days overdue (If more than 25, explain on a separate sheet) b. Does the applicant engage in suing clients for collection of fees? c. If yes, how many suits have been filed during the last two (2) years? d. What steps have been taken to reduce the number of suits for fees in the future? 7

8 25. Describe the firm s client selection process a. Does the firm perform credit checks on all clients? b. Is Management Approval required for all new clients? c. Does the firm maintain a system to avoid conflict of interests? d. Does your firm use client communication letters to include scope of service and fee arrangements? e. Does your firm use declination letters for cases where representation is declined? Section IV Claims 26. In the past five years, has any claim or suit ever been made against any current or previous member of the firm or predecessor firm (prior practice)? If yes, please enclose full particulars. 27. Are you aware of any circumstances, incidents or claims that, after making full enquiry of all principals and employees of your firm, you have not reported to your current or prior insurer? If yes, please enclose full particulars. 28. Are you aware of any circumstances, incidents or claims that, after making full enquiry of all principals and employees, that could result in a professional indemnity claim against any lawyer of the firm or its predecessors? If yes, please enclose full particulars. 29. Has the firm or any lawyer employed by the firm ever had any professional indemnity insurance company decline, cancel or refuse to renew? If yes, please enclose details. 30. Has any partner, lawyer, assistant lawyer or any other employee ever been subject of any form of disciplinary action by the Bar Association/Law Society? If yes, please enclose details. 8

9 Section V - Insurance Cover 31. Are you presently insured for professional liability? If yes, please state limit of liability, deductible and due date. Limit of liability: Deductible: Expiry date: Premium: List your Professional Indemnity Insurance carried for the past five years (information must break-down information year by year, even if information was the same for more than one year). Mark here if none: Information required; Policy Period (from to), Insurance Company, Limit of Liability (per claim and in the aggregate), Deductible, Annual Premium, Number of lawyers (incl. Partners), covered. 32. Do you request primary coverage or excess coverage? Primary coverage Excess coverage If primary coverage is requested, please state requested limit of liability per claim and annual aggregate and requested deductible per claim Limit of liability per claim and Annual aggregate: Deductible per claim: 9

10 If excess coverage is requested, please state name of primary insurer, requested limit of liability in excess of underlying coverage, underlying limit of liability, deductible, premium and insurance period Please enclose the full policy wording for the primary insurance. Name of Primary Insurer: Premium of Primary Insurance: Requested limit of liability in excess of underlying coverage: Underlying limit of liability and deductible: Insurance period: Premium: Section VI The undersigned on behalf of the applicant and all members of the firm hereby declares that he/she is authorised to make the following declarations and representations on behalf of the firm and its members. We hereby declare that the above answers, statements and particulars in this application are complete and true, and that no material facts have been suppressed, omitted or misstated. The firm has made specific inquiry to all lawyers in the firm as to their knowledge of any matters, which could result in a claim against the firm in the future. All lawyers have answered in the negative to such inquiry or where lawyers have responded other than in negative, the matters identified has been reported to the firm s current insurer. All such matters are listed in supplements to this application, and the firm acknowledges, understands and agrees that any and all claims arising out of such matters will be excluded from the Policy being applied for and any renewals of said Policy. It is agreed that this application, together with any other information supplied by us, shall form the basis of the contract, should a policy be issued, and it will be attached to and form part of the policy. Signing this application does not bind the company or the insurer to complete the insurance. Date and place: Signature: Name and Title: 10

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