LAWYERS' PROFESSIONAL LIABILITY APPLICATION - NEW YORK

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1 AB LAWYERS' PROFESSIONAL LIABILITY APPLICATION - NEW YORK THIS IS AN APPLICATION FOR CLAIMS MADE INSURANCE. THIS COVERAGE FORM CONTAINS PROVISIONS THAT REDUCE THE LIMITS OF LIABILITY AND DEDUCTIBLE STATED IN THE DECLARATIONS BY "CLAIM EXPENSES" NOT TO EXCEED FIFTY PERCENT, INCLUDING DEFENSE ATTORNEYS' FEES AND COSTS. General Information Name and Address of Applicant Firm (Street, City, State, and Zip Code): Name, telephone number and address of person to contact for information: If you have a Web site, please enter the URL here: Proposed Coverage Effective Date: / / Section I - Coverage Choices Desired Limits of Liability: $500,000 Each Claim/ $500,000 Aggregate $500,000 Each Claim/ $1,000,000 Aggregate $1,000,000 Each Claim/ $1,000,000 Aggregate $1,000,000 Each Claim/ $2,000,000 Aggregate $2,000,000 Each Claim/ $2,000,000 Aggregate Deductible: $2,500 deductible is standard. $5,000 $10,000 *$2,500 deductible not available with the $2,000,000 Each Claim/ $2,000,000 Aggregate. Some classes require a higher deductible. Current Policy Information 1. Please provide the limit of your current Lawyers Professional Liability coverage. Indicate None if the applicant currently does not have coverage and proceed to Section II. $ 2. Please provide the effective date of current LPL coverage: / / 3. Please provide the Retroactive date of current LPL coverage: / / 4. Please provide the carrier of current LPL coverage: 5. Indicate requested Retroactive date: / / 6. Has the applicant maintained/ purchased continuous Lawyers Professional Liability coverage from the requested Retroactive Date until the present? Form SS Page 1 of 5

2 Section II - Underwriting Questions 1. Are total billings per attorney greater than $500,000? 2. Is there more than one attorney in your firm? If yes, provide the number of attorneys. If no, provide the name of a back-up attorney. 3. How many non-attorney employees in the firm? 4. Does your docket control system have at least two independent controls? If you are a sole practitioner, provide the name of the other docket control person: 5. Do any members of the firm have an ownership interest or serve as a director or officer of any client's business, past or present? 6. In the past two years, have you brought suit against any client for unpaid legal fees? 7. In the last five years, have any attorney or attorneys in the firm had a professional liability claim made against them? 8. Is any member of the firm aware of any act, error or omission that could result in a professional liability claim being made? 9. In the past five years, has a professional liability insurer declined to offer coverage, non-renewed coverage or cancelled coverage for your firm? (Not applicable in Missouri) 10. Has any member of the firm (past or present) had their license to practice law revoked? 11. Has any member of the firm (past or present) been subject to disciplinary action by a governing body? 12. Has any member of the firm (past or present) been subject to a fine, reprimand or criminal penalty related to legal professional services? 13. Provide the effective date of your firm's first professional liability policy (maintained without interruption to date) 14. In the past five years, has your firm merged, been acquired, or experienced a change in membership of at least 50% of the firm's attorneys? If yes, provide the date of change. 15. Does your firm share, or has it ever shared, common office space, or any part of your premises with another law firm? IMPORTANT To avoid loss of coverage, it is imperative that all known circumstances, acts, errors, omissions, or personal injuries which could result in a professional liability claim against you, the firm, or a predecessor in business be reported to your present insurer within the time period specified in your present policy. All known claims and/or circumstances are specifically excluded by The Hartford, should coverage become effective. Page 2 of 5 Form SS

3 AREAS OF PRACTICE Based on the Applicant Firm s gross revenue for the last fiscal year, indicate the percentage of revenue derived from the following areas of practice. The total must equal 100%. (If Applicant Firm is newly established, please provide best estimate). Area of Practice % Area of Practice % Administrative % Investment Counseling/Money Management % Admiralty/Maritime Defense % Loans % Admiralty/Maritime Plaintiff % Labor Law Management % Antitrust/Trade Regulation % Labor Law Union % Arbitration/Mediation % Labor Litigation- Defense % Aviation % Labor Litigation Plaintiff % Banking/Financial Institutions % Litigation Commercial Defense % Bankruptcy % Litigation Commercial Plaintiff % BI/PI Defense % Mergers and Acquisitions % BI/PI Plaintiff Municipal/Governmental Zoning & Planning % General Liability % Municipal/Governmental Other (Not Bonds) % Medical Malpractice % Oil/Gas/Minerals % Other Plaintiff % Patent % Civil Rights/Discrimination % Public Utilities % Collection/Repossession/Foreclosures % Real Estate Communication/FCC % Real Estate Commercial % Copyright/Trademark (Not Patent) % Real Estate Escrow Agent % Corporate Formation/Alteration % Real Estate Residential % Real Estate Title Work % Corporate General % Real Estate Syndication/Development % Criminal % School Law % Family Law Securities/Bonds/Secured Transactions % Divorce % Social Security/Elder Law % All other Family Law % Taxation Eminent Domain % Tax Corporate/Business Opinions % Employee Benefit Plans/ERISA % Tax Corporate/Business Preparations % Entertainment/Sports % Tax Individual % Environmental General % Water Rights % Environmental Litigation % Wills/Estate Planning/Probate/Trusts % Foreign (Non-U.S. Law)/International % Workers Compensation Defense % Healthcare % Workers Compensation Plaintiff % Immigration % Other (Describe): Insurance % % The total must equal 100% % Form SS Page 3 of 5

4 For Utah Applicants Only: ANY MATTER IN DISPUTE BETW EEN YOU AND THE COMPANY MAY BE SUBJECT TO ARBITRAT ION AS AN ALTERNATIVE TO COURT ACTION PURSUANT TO THE RUL ES OF (THE AM ERICAN ARBI TRATION ASSOCIATION OR OTHER RECOGNI ZED ARBITRAT OR), A COPY OF WHICH IS AVAILABLE ON REQUEST F ROM THE COM PANY. ANY DECISI ON REACHED BY ARBITRATION SHALL BE BINDING UPON BOTH Y OU AND THE COM PANY. THE ARBI TRATION AWARD MAY INCLUDE ATTORNEY 'S FEES IF ALLOWED BY STATE LAW AND MAY BE ENTERED AS A JUDGEM ENT IN ANY COURT OF PROPER JURISDICTION. FRAUD WARNING STATEMENTS ARKANSAS APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEF IT OR KNOW INGLY PRESENTS FALSE INFORM ATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO F INES AND CONFI NEMENT IN PRISON. COLORADO APPLICANTS: IT IS UNLAWFUL TO KNOWINGLY PROVI DE 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 INSURAN CE AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO KNOW INGLY PROVI DES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICY HOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICY HOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORT ED TO THE COLORADO DI VISION OF INSURANCE W ITHIN THE DEPARTMENT OF REGUL ATORY AGENCI ES. DISTRICT OF COLUM BIA APPLICANTS: WARNING IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORM ATION 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 BENEFI TS IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVI DED BY THE APPL ICANT. " FLORIDA APPLICANTS: ANY PERSON WHO KNOW INGLY AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORM ATION IS GUILTY OF A FELONY OF THE THIRD DEGREE. HAWAII APPLICANTS: FOR YOUR PROTECT ION, HAWAII LAW REQUI RES YOU TO BE INFORM ED THAT PRESENTING A FRAUDUL ENT CLAIM FOR PAYMENT OF A LOSS OR BENEF IT IS A CRIME PUNISHABLE BY FINES OR IMPRISONM ENT, OR BOTH. KENTUCKY APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANC E CONTAINI NG ANY MATERIALLY FALSE INFORM ATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORM ATION CONCERNING ANY FACT MATERIAL THERET O COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME. LOUISIANA APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENT S A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEF IT OR KNOW INGLY PRESENTS FALSE INFORM ATION IN AN APPLICATION FOR INSURAN CE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO F INES AND CONFI NEMENT IN PRISON. MAINE APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOM PLETE OR MISLEADING INFORM ATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONM ENT, FINES OR A DENIAL OF INSURANCE BENEF ITS. NEW JERSEY APPLICANTS: ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORM ATION ON AN APPLICATION FOR AN INSURANCE POL ICY IS SUBJECT TO CRI MINAL AND CI VIL PENALTIES. NEW MEXICO APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENT S A FALSE OR FRAUDUL ENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORM ATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CR IMINAL PENALTIES. NEW YORK 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 MATERIAL FACT THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL BE ALSO SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION. OHIO APPLICANTS: ANY PERSON WHO, WITH INTENT TO DEF RAUD 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. OKLAHOM A APPLICANTS: WARNING: ANY PERSON WHO KNOW INGLY, AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER, MAKES ANY CLAIM FOR THE PROCEED S OF AN INSURANCE POLICY CONTAINI NG ANY FALSE, INCOMPLETE OR MISLEADING INFORM ATION IS GUILTY OF A FELONY. OREGON APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD OR SOLICIT ANOTHER TO DEFRAU D AN INSURER: (1) BY SUBMITTING AN APPLICATION OR; (2) FILING A CLAIM CONTAINING A FALSE STATEMENT AS TO ANY MATERIAL FACT MAYBE VIOLATING STATE LAW. Page 4 of 5 Form SS

5 PENNSY LVANIA APPLICANTS: ANY PERSON WHO KNOW INGLY 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 CONCERNI NG ANY FACT MATERIAL THERET O COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. TENNESSEE: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOM PLETE OR MISLEADING INFORM ATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFI TS. VIRGINIA APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOM PLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFI TS. WEST VIRGINIA: ANY PERSON WHO KNOW INGLY PRESENT S A FALSE OR FRAUDUL ENT CLAIM FOR PAYMENT OF A LOSS OR BENEFI T OR KNOW INGLY PRESENT S FALSE INFORM ATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONF INEMENT IN PRISON. SIGNING THIS FORM DOES NOT BIND THE APPLICANT FIRM OR THE COMPANY TO COMPLETE THE INSURANCE. APPLICATION MUST BE SIGNED AND DATED BY AN OWNER, PARTNER, OR OFFICER OF THE APPLICANT FIRM. APPLICANT S STATEMENT: I, being duly authorized, have read the above application and declare that to the best of my knowledge and belief all of the foregoing statements are true, and that these statements are offered as an inducement to the Company to issue the policy for which I am applying. (Kansas: This does not constitute a warranty). Authorized Signature: Title: Print Name: Date: Producer s Signature: Title: Print Name: Date: License Identification Number or National Producer Number: (Florida Producers must provide License Identification Number) First State Insurance Company Hartford Accident and Indemnity Company Hartford Casualty Insurance Company Hartford Fire Insurance Company Hartford Insurance Company of Illinois Hartford Insurance Company of the Midwest Hartford Insurance Company of the Southeast Hartford Lloyd's Insurance Company Hartford Underwriters Insurance Company New England Insurance Company New England Reinsurance Corporation Nutmeg Insurance Company Omni Indemnity Company Omni Insurance Company Pacific Insurance Company, Limited Property and Casualty Insurance Company of Hartford Sentinel Insurance Company, Ltd. Trumbull Insurance Company Twin City Fire Insurance Company Form SS Page 5 of 5

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