KENTUCKY APPLICATION FOR LAWYERS PROFESSIONAL LIABILITY INSURANCE
|
|
- Lilian Matthews
- 8 years ago
- Views:
Transcription
1 PROFESSIONAL LIABILITY (OTHER THAN MEDICAL) LW AP KENTUCKY APPLICATION FOR LAWYERS PROFESSIONAL LIABILITY INSURANCE THIS APPLICATION IS FOR A CLAIMS-MADE AND REPORTED POLICY. CLAIMS MUST BE FIRST MADE AGAINST THE INSURED DURING THE POLICY PERIOD OR EXTENDED REPORTING PERIOD, IF APPLICABLE, AND REPORTED TO US AS SOON AS PRACTICABLE, BUT IN NO EVENT LATER THAN THIRTY (30) DAYS AFTER THE END OF THE POLICY PERIOD, OR AFTER THE END OF THE EXTENDED REPORTING PERIOD, IF APPLICABLE. THE INSURANCE FOR WHICH THIS APPLICATION IS MADE APPLIES ONLY IF THE WRONGFUL ACT OUT OF WHICH THE CLAIM AROSE OCCURRED ON OR AFTER THE RETROACTIVE DATE, IF ANY, SHOWN IN THE DECLARATIONS AND BEFORE THE END OF THE POLICY PERIOD. DAMAGES AND DEFENSE EXPENSES ARE PAYABLE WITHIN THE LIMITS OF INSURANCE. IF ISSUED, PLEASE READ YOUR POLICY CAREFULLY. Name Of Applicant Or Firm: SECTION I GENERAL INFORMATION Mailing Address Of Principal Office: Phone Number: Firm's Web Site: Fax Number: Firm's Address: Branch Office? If, please provide Mailing Address(es): Branch Office Mailing Address: Phone Number: Fax Number: Branch Office Mailing Address: Phone Number: Fax Number: LW AP Insurance Services Office, Inc., 2010 Page 1 of 8
2 Date Firm Was Established: Type Of Firm: Sole Practitioner Partnership Professional Association or Corporation Limited Liability Partnership Limited Liability Company Other (describe): Provide Name Of Predecessor Firms And Dates Of Existence: Has your firm's lawyers professional liability insurance ever been canceled or nonrenewed for reasons other than nonpayment of premium? If, please explain: SECTION II COVERAGE REQUESTED Limit Of Insurance: Each Claim $ Limit Of Insurance: Aggregate $ Deductible: $ Proposed Effective Date: Proposed Retroactive Date: SECTION III ATTORNEY INFORMATION Attorney Name P A O I Parttime* Fulltime State(s) Licensed In/Year Total. Years In Practice P = Partner A = Associate O = Of Counsel I = Independent Contractor * Part-time = An attorney working less than 1,000 hours during the annual policy period Page 2 of 8 Insurance Services Office, Inc., 2010 LW AP
3 Has the license(s) of any attorney listed above ever been suspended or revoked? If, please explain: Number Of Paralegals Number Of Clerks Number Of Other Employees AREAS OF PRACTICE Area Of Practice % Area Of Practice % Admiralty/Maritime Defense Intellectual Property Patent Admiralty/Maritime Plaintiff Intellectual Property Trademark Antitrust/Trade Regulation Investment Counseling/Money Management Arbitration/Mediation Labor/Employment Employee Aviation Labor/Employment Management Banking/Financial Institutions Labor/Employment Union Bankruptcy Litigation Defense Bodily Injury/Personal Injury Defense Litigation Plaintiff Bodily Injury/Personal Injury Plaintiff Medical Malpractice Defense Civil Rights/Discrimination Medical Malpractice Plaintiff Class Action Defense Mergers/Acquisitions Class Action Plaintiff Municipal/Government Zoning And Planning Collection/Repossession/Foreclosures Municipal/Government Other (t Bonds) Communications/FCC Oil/Gas/Minerals Construction (Building Contracts) Public Utilities Consumer Claims (t Class Action) Real Estate Commercial Corporate (Other Than Mergers And Real Estate Escrow Agent Acquisitions) Criminal Real Estate Residential Divorce Real Estate Syndication/Development Employee Benefits/ERISA/Pension Real Estate Title Work Entertainment/Sports Securities/Bonds/Secured Transactions Environmental Social Security/Elder Family (Other Than Divorce) Tax Business Foreign/International Tax Individual Healthcare Tax Opinion Immigration Wills/Estates/Trusts/Probate LW AP Insurance Services Office, Inc., 2010 Page 3 of 8
4 Insurance Intellectual Property Copyright Workers' Compensation Defense Workers' Compensation Plaintiff Other (Describe): TOTAL MUST EQUAL 100% Lawyers Who Currently Hold Position Or Capacity In Other Than The Named Insured Firm % Of Ownership Name Of Lawyer Name Of Business Nature Of Business Position Interest SECTION IV SYSTEMS AND PROCEDURES Does your firm have procedures in place that include the regular use of a centralized conflict of interest avoidance system when accepting new clients or a new matter from existing clients? Does or has any current or former attorney of your firm served as an officer, director, partner, employee, principal shareholder or member or in any other management capacity for a client? If, please explain: Does any attorney in the firm have an equity interest in any one client? If, please explain: Does the firm use a peer review system to evaluate the performance of partners or officers? Does the firm maintain a planned docket control system and procedure with at least two independent date controls? Is the docket control system and procedure computerized? Does the planned docket control system and procedure produce a weekly calendar? Page 4 of 8 Insurance Services Office, Inc., 2010 LW AP
5 Does the planned docket control system and procedure cover all aspects of the firm's practice? Does the planned docket control system and procedure require lawyers to both calendar and remove from calendar all filing dates? Are open calendar entries on the planned docket control system and procedure circulated to all lawyers or, if the firm is divided into formal departments, to all lawyers in the appropriate department? Is the firm managed by a management committee? If, answer the following: How many partners or officers comprise the management committee? Does the firm employ an administrator? What percentage of the administrator's time is devoted to the practice of law? % Does the firm sue clients for fees? If so, how many times in the past three years? Does the firm issue engagement or disengagement letters to clients? SECTION V FIRM'S INSURANCE COVERAGE HISTORY Prior Insurance Information: (List prior lawyers professional liability insurance for the past three years, both stand-alone policies and supplemental coverage provided under some other type of insurance.) Period Period Period Insurer Insurer Insurer Limit Of Insurance Limit Of Insurance Limit Of Insurance $ $ $ LW AP Insurance Services Office, Inc., 2010 Page 5 of 8
6 Deductible Deductible Deductible $ $ $ Premium Premium Premium $ $ $ Number Of Lawyers Number Of Lawyers Number Of Lawyers Coverage is requested to be effective on: Provide the date of the Applicant Firm's first claims-made policy (maintained without interruption to date): Does your firm's current policy contain a prior acts limitation or retroactive date applicable to your firm or any individual attorney? If, please provide date: Attach a copy of the endorsement. Has your firm ever purchased an Extended Reporting Period option? If, provide the full details: SECTION VI CLAIM/INCIDENT/DISCIPLINARY INFORMATION Has anyone in the firm ever been convicted of or pled guilty to a crime? Is there currently any pending litigation or claims against the named applicant, firm and/or any of the insured attorneys? This includes disciplinary actions, malpractice claims, any act, error or omission, or other circumstance which could be expected to give rise to a claim. Are any of the insured attorneys aware of any matters that could potentially give rise to a claim? If so, approximately when did those insured attorneys become aware of any such matters? Page 6 of 8 Insurance Services Office, Inc., 2010 LW AP
7 Include the nature of the allegations or potential claim, the disposition (damages/settlements) and/or final payment, if any, in the space provided below. If more space is necessary, use Form LW AP 01: Name Of The Insured Attorney(s) Involved: Name Of Claimant/Litigation Or Potential Claim/Litigation Involved: Dates Of Litigation Involved (If Applicable): Status Of Litigation (If Applicable): Summary Of Allegations/Amount Of Damages At Issue (If Applicable): Applicant's fiscal year ends on: Month: Day: Indicate the gross income for the applicable fiscal year (gross income means all sums billed to clients for services rendered): (a) Actual gross income for second previous fiscal year: $ (b) Actual gross income for immediate past fiscal year: $ (c) Estimated gross income for current fiscal year: $ LW AP Insurance Services Office, Inc., 2010 Page 7 of 8
8 FRAUD STATEMENT 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 fact material thereto, commits a fraudulent insurance act, which is a crime. NOTICE TO APPLICANT PLEASE READ CAREFULLY FOR THE PURPOSE OF THIS APPLICATION, THE UNDERSIGNED REPRESENTS THAT TO THE BEST OF HIS/HER KNOWLEDGE THE STATEMENTS HEREIN ARE TRUE AND COMPLETE. THE INSURER IS AUTHORIZED TO MAKE ANY INQUIRY IN CONNECTION WITH THIS APPLICATION. SIGNING THIS APPLICATION DOES NOT BIND THE INSURER TO ISSUE, OR THE APPLICANT TO PURCHASE, ANY INSURANCE POLICY. THE INFORMATION CONTAINED IN AND SUBMITTED WITH THIS APPLICATION IS ON FILE WITH THE INSURER. THIS APPLICATION WILL BECOME A PART OF SUCH POLICY, IF ISSUED. THE INSURER WILL HAVE RELIED UPON THIS APPLICATION AND ATTACHMENTS IN ISSUING THIS POLICY. IN THE EVENT THAT THE APPLICATION CONTAINS ANY MISREPRESENTATION OR MISSTATEMENT OF A MATERIAL FACT, THIS POLICY SHALL NOT AFFORD COVERAGE TO ANY INSURED WHO KNEW OF SUCH MISREPRESENTATION OR MISSTATEMENT. IF THE INFORMATION IN THIS APPLICATION MATERIALLY CHANGES PRIOR TO THE EFFECTIVE DATE OF THE POLICY, THE APPLICANT MUST PROVIDE WRITTEN NOTIFICATION TO THE INSURER, WHO MAY MODIFY OR WITHDRAW THE QUOTATION. THE UNDERSIGNED FURTHER AGREES TO AUTHORIZE THE RELEASE OF ANY AND ALL INFORMATION IN THIS APPLICATION TO A LOSS CONTROL PROVIDER THAT PROVIDES LOSS CONTROL SERVICES TO THE INSURER AND TO COMPLY WITH THE TERMS AND CONDITIONS OF THOSE LOSS CONTROL SERVICES. THE UNDERSIGNED DECLARES THAT THE INDIVIDUALS AND ORGANIZATIONS PROPOSED FOR THIS INSURANCE HAVE BEEN NOTIFIED THAT: A. THIS POLICY APPLIES ONLY TO CLAIMS FIRST MADE OR DEEMED MADE AGAINST THE INSURED DURING THE POLICY PERIOD OR ANY EXTENDED REPORTING PERIOD, IF APPLICABLE; AND B. THE LIMIT OF LIABILITY IS REDUCED BY AMOUNTS INCURRED AS DAMAGES AND SUCH EXPENSES WILL BE SUBJECT TO THE DEDUCTIBLE AMOUNT. NOTE: This application must be signed by the officer or partner of the first Named Insured firm acting as the authorized officer or partner of the applicant applying for this insurance. Printed Name Of Officer Or Partner Of The Firm: Signature Of Officer Or Partner Of The Firm: Title: Date: Page 8 of 8 Insurance Services Office, Inc., 2010 LW AP
Twin City Fire Insurance Company Name of Insurance Company to which Application is made
Twin City Fire Insurance Company Name of Insurance Company to which Application is made FLORIDA THE HARTFORD PREMIER LAWYERS PROFESSIONAL LIABILITY INSURANCE APPLICATION This is an application for a CLAIMS-MADE
More informationLAWYERS PROFESSIONAL LIABILITY NEW BUSINESS APPLICATION
ASPEN AMERICAN INSURANCE COMPANY LAWYERS PROFESSIONAL LIABILITY NEW BUSINESS APPLICATION NOTICE: This is an application for a claims-made and reported policy. Coverage for prior acts and claims made after
More informationLawyers Professional Liability Application
Lawyers Professional Liability Application NOTICE: THIS IS AN APPLICATION FOR A CLAIMS-MADE POLICY, WHICH SUBJECT TO ITS PROVISIONS APPLIES ONLY TO CLAIMS WHICH ARE FIRST MADE AGAINST THE INSURED DURING
More informationLAWYERS PROFESSIONAL LIABILITY
NAVIGATORS INSURANCE COMPANY (NAV) NAVIGATORS SPECIALTY INSURANCE COMPANY (NSIC) LAWYERS PROFESSIONAL LIABILITY NOTICE: This is an application for a Claims-made policy. Coverage for prior acts and claims
More informationTravelers 1 st Choice LAWYERS PROFESSIONAL LIABILITY COVERAGE SMALL LAW FIRM APPLICATION
Travelers Casualty and Surety Company of America Hartford, Connecticut Travelers 1 st Choice LAWYERS PROFESSIONAL LIABILITY COVERAGE SMALL LAW FIRM APPLICATION Important Note: This is an application for
More informationDESIGNED PROTECTION SM FOR LAW FIRMS APPLICATION FOR LAWYERS PROFESSIONAL LIABILITY INSURANCE
DESIGNED PROTECTION SM FOR LAW FIRMS APPLICATION FOR LAWYERS PROFESSIONAL LIABILITY INSURANCE NOTICE: THE POLICY FOR WHICH APPLICATION IS MADE APPLIES ONLY TO CLAIMS FIRST MADE DURING THE POLICY PERIOD.
More informationNEW YORK LAWYERS PROFESSIONAL LIABILITY APPLICATION
UNITED STATES FIRE INSURANCE COMPANY THE NORTH RIVER INSURANCE COMPANY 305 MADISON AVENUE, MORRISTOWN, NJ 07962 NEW YORK LAWYERS PROFESSIONAL LIABILITY APPLICATION NOTICE: COVERAGE FOR WHICH THIS APPLICATION
More informationAPPLICATION FOR LAWYERS PROFESSIONAL LIABILITY INSURANCE
IRONSHORE INDEMNITY INC. 1 Exchange Plaza (55 Broadway) 12 th Floor New York, NY 10006 (877) IRON411 APPLICATION FOR LAWYERS PROFESSIONAL LIABILITY INSURANCE NOTICE: This professional liability coverage
More informationAPPLICATION FOR LAWYERS PROFESSIONAL LIABILITY INSURANCE
APPLICATION FOR LAWYERS PROFESSIONAL LIABILITY INSURANCE THIS APPLICATION IS FOR A CLAIMS MADE AND REPORTED INSURANCE POLICY. IF A POLICY IS ISSUED, THE LIMITS OF LIABILITY AND DEDUCTIBLE WILL APPLY TO,
More informationPhiladelphia Insurance Companies
Philadelphia Insurance Companies One Bala Plaza, Suite 100, Bala Cynwyd, Pennsylvania 19004 APPLICATION FOR: LAWYERS PROFESSIONAL LIABILITY INSURANCE NOTICE: This professional liability coverage is provided
More informationLAWYERS PROFESSIONAL LIABILITY INSURANCE APPLICATION
LAWYERS PROFESSIONAL LIABILITY INSURANCE APPLICATION ProAssurance Casualty Company PO Box 150 Okemos, MI 48805-0150 800.292.1036 517.349.6500 Fax 517.347.6321 NOTICE: This professional liability coverage
More informationPROFESSIONAL LIABILITY INSURANCE APPLICATION FOR LAW FIRMS
James River Insurance Company and its Subsidiaries 6641 West Broad Street, Suite 300 Richmond, VA 23230 Application for Law Firms Lawyers Professional Liability PROFESSIONAL LIABILITY Division Email to
More informationLawyers Professional Liability Insurance Application
Lawyers Professional Liability Insurance Application AMERICAN GUARANTEE AND LIABILITY INSURANCE COMPANY THIS APPLICATION IS FOR A CLAIMS-MADE AND REPORTED POLICY. IF ISSUED, PLEASE READ YOUR POLICY CAREFULLY.
More informationTWIN CITY FIRE INSURANCE COMPANY Name of Insurance Company to which Application is made LAWYERS PROFESSIONAL LIABILITY INSURANCE APPLICATION
TWIN CITY FIRE INSURANCE COMPANY Name of Insurance Company to which Application is made LAWYERS PROFESSIONAL LIABILITY INSURANCE APPLICATION This is an application for a CLAIMS-MADE AND REPORTED Policy
More informationMINNESOTA LAWYERS PROFESSIONAL LIABILITY SECTION
AGENCY MINNESOTA LAWYERS PROFESSIONAL LIABILITY SECTION CARRIER DATE NAIC CODE POLICY NUMBER EFFECTIVE DATE NAMED INSURED DBA: NOTICE: THIS APPLICATION IS FOR CLAIMS-MADE AND REPORTED COVERAGE, WHICH APPLIES
More informationLAW FIRMS ERRORS & OMISSIONS APPLICATION
APPLICANT S INFORMATION: LEGAL NAME OF FIRM: BUSINESS ADDRESS: COUNTY: DATE FIRM ESTABLISHED: LAW FIRMS ERRORS & OMISSIONS APPLICATION WEB ADDRESS: DATE PRESENT OWNERSHIP ASSUMED CONTROL: Corporation Individual
More informationEZ RENEWAL APPLICATION FOR LAWYERS PROFESSIONAL LIABILITY INSURANCE ABOUT THE FIRM RENEWAL INFORMATION
EZ RENEWAL APPLICATION FOR LAWYERS PROFESSIONAL LIABILITY INSURANCE THE POLICY YOU ARE APPLYING FOR IS A CLAIMS-MADE AND REPORTED POLICY, AND SUBJECT TO ITS PROVISIONS, APPLIES ONLY TO ANY CLAIM BOTH FIRST
More informationLAW FIRMS ERRORS & OMISSIONS APPLICATION
APPLICANT S INFORMATION: LEGAL NAME OF FIRM: BUSINESS ADDRESS: COUNTY: DATE FIRM ESTABLISHED: LAW FIRMS ERRORS & OMISSIONS APPLICATION WEB ADDRESS: DATE PRESENT OWNERSHIP ASSUMED CONTROL: Corporation Individual
More informationLAWYERS PROFESSIONAL LIABILITY APPLICATION
LAWYERS PROFESSIONAL LIABILITY APPLICATION If the space given is insufficient, please attach a separate sheet referenced to the specific question being answered. 1. A. Name of Applicant Firm: Partnership:
More informationNAVIGATORS INSURANCE COMPANY
NAVIGATORS INSURANCE COMPANY APPLICATION FOR LAWYERS' PROFESSIONAL LIABILITY INSURANCE THIS APPLICATION IS FOR A CLAIMS MADE AND REPORTED POLICY (must complete in ink) 1. Name of Applicant (type or print)
More informationGENERAL CLIENT INFORMATION (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
LAWYERS PROFESSIONAL LIABILITY SECTION DATE AGENCY CARRIER NAIC CODE POLICY NUMBER EFFECTIVE DATE NAMED INSURED DBA: NOTICE: THIS APPLICATION IS FOR CLAIMS-MADE AND REPORTED COVERAGE, WHICH APPLIES ONLY
More informationAPPLICATION FOR LAWYERS PROFESSIONAL LIABILITY INSURANCE
Page 1 of 7 IMPORTANT NOTICE THE POLICY FOR WHICH YOU ARE APPLYING IS WRITTEN ON A CLAIMS_MADE BASIS. IT PROVIDES NO COVERAGE FOR CLAIMS ARISING OUT OF INCIDENTS, SITUATIONS OR ACTS OR OMISSIONS WHICH
More informationLawyers Professional Liability Application
Lawyers Professional Liability Application NOTICE: This is an application for a claims made and reported policy. This policy covers only claims first made and reported during the policy period or extended
More informationAPPLICATION FOR PRIVATE PRACTICE CLAIMS-MADE
APPLICATION FOR PRIVATE PRACTICE CLAIMS-MADE LAWYERS PROFESSIONAL LIABILITY INSURANCE FIRM INFORMATION 1. Firm Name: Primary Contact (please indicate Mr., Ms, etc.): E-Mail Address: Cell Phone Number:
More informationAPPLICATION FOR LAWYERS PROFESSIONAL LIABILITY INSURANCE IMPORTANT NOTICE
IMPORTANT NOTICE THE POLICY FOR WHICH YOU ARE APPLYING IS WRITTEN ON A CLAIMS-MADE BASIS. IT PROVIDES NO COVERAGE FOR CLAIMS ARISING OUT OF INCIDENTS, SITUATIONS OR ACTS OR OMISSIONS WHICH TOOK PLACE PRIOR
More informationLAWYERS PROFESSIONAL LIABILITY INSURANCE APPLICATION
DARWIN NATIONAL ASSURANCE COMPANY 1690 New Britain Avenue, Suite 101, Farmington, CT 06032 Tel. (860) 284-1300 Fax (860) 284-1301 LAWYERS PROFESSIONAL LIABILITY INSURANCE APPLICATION NOTICE: THE POLICY
More information2. a. Primary Location of the firm: Street Address: City: County: State: Zip: Telephone: Fax:
THE POLICY YOU ARE APPLYING FOR IS A CLAIMS-MADE AND REPORTED POLICY, AND SUBJECT TO ITS PROVISIONS, APPLIES ONLY TO ANY CLAIM BOTH FIRST MADE AGAINST AN INSURED AND REPORTED IN WRITING TO THE COMPANY
More informationTravelers 1 st Choice ACCOUNTANTS PROFESSIONAL LIABILITY COVERAGE SMALL ACCOUNTING FIRM APPLICATION
Travelers 1 st Choice ACCOUNTANTS PROFESSIONAL LIABILITY COVERAGE SMALL ACCOUNTING FIRM APPLICATION SM Travelers Casualty and Surety Company of America Hartford, Connecticut Important Note: This is an
More informationTWIN CITY FIRE INSURANCE COMPANY Name of Insurance Company to which Application is made NEW YORK ACCOUNTANTS PROFESSIONAL LIABILITY APPLICATION
TWIN CITY FIRE INSURANCE COMPANY Name of Insurance Company to which Application is made NEW YORK ACCOUNTANTS PROFESSIONAL LIABILITY APPLICATION NOTICE: THIS IS A CLAIMS-MADE POLICY. THE COVERAGE OF THIS
More informationCopyright or Trademark Criminal Defense. Licensing/Trade Secret
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:
More informationBerkley Insurance Company
Lawyers Professional Liability Insurance New Business Application CLAIMS MADE WARNING FOR APPLICATION: This Application is for a Claims Made and Reported Policy, relating to claims made against the Insureds
More informationREALCARE INSURANCE MARKETING, INC. Real Estate Professionals Errors and Omissions Insurance Application
REALCARE INSURANCE MARKETING, INC. Real Estate Professionals Errors and Omissions Insurance Application NOTICE: This is an application for a Claims-made policy. Coverage for prior acts and claims made
More informationOneBeacon Insurance Company Lawyers Professional Liability Moonlighting Legal Services Application
OneBeacon Insurance Company Lawyers Professional Liability Moonlighting Legal Services Application NOTICE: This is an application for a claims-made and reported policy. Subject to its terms, this policy
More informationLawyers Professional Liability Application
Lawyers Professional Liability Application NOTICE: THIS IS AN APPLICATION FOR A CLAIMS-MADE AND REPORTED POLICY, WHICH SUBJECT TO ITS PROVISIONS APPLIES ONLY TO CLAIMS WHICH ARE BOTH FIRST MADE AGAINST
More information1. A. Name of Applicant: Partnership Limited Liability Partnership. B. Street / Mailing Address: City: County:
Insurer: J A M I S O N P R O A P P L I C A T I O N I N T E L L E C T U A L P R O P E R T Y L A W Y E R S P R O F E S S I O N A L L I A B I L I T Y I N S U R A N C E N O T I C E : T H I S I S A N A P P
More informationBEDFORD UNDERWRITERS, LTD.
BEDFORD UNDERWRITERS, LTD. 315 East Mill St., P. O. Box 278 Plymouth, WI 53073 Ph. (920) 892-8795 (800) 735-1378 FAX (920) 892-8980 APPLICATION FOR LAWYERS PROFESSIONAL LIABILITY INSURANCE (Claims Made
More informationLAWYERS PROFESSIONAL LIABILITY INSURANCE
APPLICATION FOR: LAWYERS PROFESSIONAL LIABILITY INSURANCE NOTICE: This professional liability coverage is provided on a claims-made basis; therefore, only claims which are first made against you, and reported
More informationNAVIGATORS INSURANCE COMPANY
NAVIGATORS INSURANCE COMPANY APPLICATION FOR LAWYERS' PROFESSIONAL LIABILITY INSURANCE THIS APPLICATION IS FOR A CLAIMS MADE AND REPORTED POLICY (must complete in ink) 1. Name of Applicant (type or print)
More informationNAVIGATORS INSURANCE COMPANY
NAVIGATORS INSURANCE COMPANY APPLICATION FOR LAWYERS' PROFESSIONAL LIABILITY INSURANCE NOTICE THE POLICY YOU ARE APPLYING FOR IS A CLAIMS-MADE POLICY WITH CLAIMS EXPENSES INCLUDED WITHIN BOTH THE APPLICABLE
More informationLawyers Professional Liability Insurance New Business Application Underwritten by The Hanover Insurance Company
Hanover Professional Portfolio Lawyers Professional Liability Insurance New Business Application Underwritten by The Hanover Insurance Company CLAIMS-MADE WARNING FOR APPLICATION THIS APPLICATION IS FOR
More informationState National Insurance Company Torus Specialty Insurance Company
State National Insurance Company Torus Specialty Insurance Company APPLICATION FOR: LAWYERS PROFESSIONAL LIABILITY INSURANCE NOTICE: This professional liability coverage is provide on a claims-made basis;
More informationLawyers Professional Liability Insurance Application New York. Website: E-mail:
NOTICE: THIS IS A CLAIMS MADE POLICY. THIS POLICY COVERS ONLY CLAIMS FIRST MADE DURING THE POLICY PERIOD OR EXTENDED REPORTING PERIOD, IF APPLICABLE, AND OTHERWISE COVERED BY THIS INSURANCE. THIS POLICY
More informationLawyers Professional Liability Insurance Application Illinois. Website: E-mail:
NOTICE: THIS IS A CLAIMS MADE POLICY. THIS POLICY COVERS ONLY CLAIMS FIRST MADE DURING THE POLICY PERIOD OR EXTENDED REPORTING PERIOD, IF APPLICABLE, AND OTHERWISE COVERED BY THIS INSURANCE. Lawyers Professional
More informationRADIGAN INSURANCE O: 866-576-0977 F: 877-576-0101 E: SERVICE@RAIDGANINSURANCE.COM W: RADIGANINSURANCE.COM
RADIGAN INSURANCE O: 866-576-0977 F: 877-576-0101 E: SERVICE@RAIDGANINSURANCE.COM W: RADIGANINSURANCE.COM NOTICE: THIS IS A CLAIMS MADE POLICY. THIS POLICY COVERS ONLY CLAIMS FIRST MADE DURING THE POLICY
More informationAPPLICATION FOR LAWYERS PROFESSIONAL LIABILITY INSURANCE (Claims Made and Reported Basis)
James River Insurance Company 6767 Forest Hill Avenue, Suite 305 Richmond, VA 23225 (804) 560-1550 1. APPLICANT INFORMATION APPLICATION FOR LAWYERS PROFESSIONAL LIABILITY INSURANCE (Claims Made and Reported
More informationLAWYERS PROFESSIONAL LIABILITY INSURANCE POLICY APPLICATION
LAWYERS PROFESSIONAL LIABILITY INSURANCE POLICY APPLICATION NOTICE: THE POLICY FOR WHICH THIS APPLICATION IS MADE IS A CLAIMS MADE AND REPORTED POLICY. SUBJECT TO ITS TERMS, THE POLICY APPLIES ONLY TO
More informationTravelers 1 st Choice REAL ESTATE SERVICES PROFESSIONAL LIABILITY COVERAGE APPLICATION
Travelers 1 st Choice REAL ESTATE SERVICES PROFESSIONAL LIABILITY COVERAGE APPLICATION Travelers Casualty and Surety Company of America Hartford, Connecticut IMPORTANT NOTE: This is an application for
More informationAPPLICATION FOR LAWYERS PROFESSIONAL LIABILITY INSURANCE (CLAIMS-MADE AND REPORTED BASIS)
APPLICATION FOR LAWYERS PROFESSIONAL LIABILITY INSURANCE (CLAIMS-MADE AND REPORTED BASIS) INSTRUCTIONS (Please Print or Type All Replies) (a) If any space provided herein is insufficient for complete reply,
More informationAPPLICATION FOR ACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE
Executive Risk Indemnity Inc. Home Office Wilmington, Delaware 19805-1297 Administrative Offices/Mailing Address: 82 Hopmeadow Street Simsbury, Connecticut 06070-7683 APPLICATION FOR ACCOUNTANTS PROFESSIONAL
More informationTORUS NATIONAL INSURANCE COMPANY Harborside Financial Center Plaza 5, Suite 2900 Jersey City, New Jersey 07311 888-220-8477
TORUS NATIONAL INSURANCE COMPANY Harborside Financial Center Plaza 5, Suite 2900 Jersey City, New Jersey 07311 888-220-8477 APPLICATION FOR EMPLOYMENT PRACTICES LIABILITY INSURANCE NOTICE TO ALL APPLICANTS:
More informationLawyers Professional Liability Insurance New Business Application
a member of the Hanover Group Lawyers Professional Liability Insurance Lawyers Professional New Business Liability ApplicationInsurance New Business Application CLAIMS-MADE WARNING FOR APPLICATION THIS
More informationProfessional Risk Facilities,
P R F Professional Risk Facilities, MISCELLANEOUS PROFESSIONAL LIABILITY ERRORS & OMISSIONS APPLICATION NOTICE: THIS IS AN APPLICATION FOR A CLAIMS-MADE AND REPORTED POLICY WHICH, SUBJECT TO ITS PROVISIONS,
More informationPearl Insurance 1200 E.Glen Ave. Peoria Heights, IL 61616
GENERAL STAR NATIONAL INSURANCE COMPANY (Referred to as General Star ) APPLICATION NEW YORK ACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE Pearl Insurance 1200 E.Glen Ave. Peoria Heights, IL 61616 NOTICE
More informationALLIED WORLD LPL ASSURE LAWYERS PROFESSIONAL LIABILITY INSURANCE POLICY RENEWAL INSURANCE APPLICATION
ALLIED WORLD INSURANCE COMPANY 1690 New Britain Avenue, Suite 101, Farmington, CT 06032 Tel. 860-284-1300 Fax 860-284-1319 ALLIED WORLD LPL ASSURE LAWYERS PROFESSIONAL LIABILITY INSURANCE POLICY RENEWAL
More informationLAWYERS PROFESSIONAL LIABILITY INSURANCE POLICY RENEWAL APPLICATION
LAWYERS PROFESSIONAL LIABILITY INSURANCE POLICY RENEWAL APPLICATION NOTICE: THE POLICY FOR WHICH THIS APPLICATION IS MADE IS A CLAIMS MADE AND REPORTED POLICY. SUBJECT TO ITS TERMS, THE POLICY APPLIES
More informationMiscellaneous Professional Liability Application
Name of insurance company to which Application is made (the Insurer ) Miscellaneous Professional Liability Application NOTICE: THE POLICY PROVIDES THAT THE LIMIT OF LIABILITY AVAILABLE TO PAY JUDGEMENTS
More informationAPPLICATION FOR LAWYERS PROFESSIONAL LIABILITY INSURANCE (CLAIMS-MADE AND REPORTED BASIS)
APPLICATION FOR LAWYERS PROFESSIONAL LIABILITY INSURANCE (CLAIMS-MADE AND REPORTED BASIS) INSTRUCTIONS (Please Print or Type All Replies) (a) If any space provided herein is insufficient for complete reply,
More informationProperty Managers Errors & Omissions and Commercial Crime Application
Property Managers Errors & Omissions and Commercial Crime Application Brought to you by Aon NOTICE WITH RESPECT TO ALL COVERAGE PARTS, THE POLICY YOU ARE APPLYING FOR IS A CLAIMS-MADE POLICY, AND SUBJECT
More informationPROFESSIONAL LIABILITY INSURANCE Application for "Claims Made" Policy
Applicant's Instructions: PROFESSIONAL LIABILITY INSURANCE Application for "Claims Made" Policy ANSWER ALL QUESTIONS. If the answer to any question is None or Not Applicable, Please state "NO". If space
More informationLAWYERS' PROFESSIONAL LIABILITY APPLICATION - NEW YORK
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
More informationReferred by the Columbus Bar Association
Supplemental forms can be printed from: https://www.oblic.com/our-policies/policy-forms/ Referred by the Columbus Bar Association APPLICATION FOR LAWYERS PROFESSIONAL LIABILITY INSURANCE (CLAIMS-MADE AND
More informationALLIED WORLD INSURANCE COMPANY 1690 New Britain Avenue, Suite 101, Farmington, CT 06032 Tel. 860-284-1300 Fax 860-284-1319
ALLIED WORLD INSURANCE COMPANY 1690 New Britain Avenue, Suite 101, Farmington, CT 06032 Tel. 860-284-1300 Fax 860-284-1319 ALLIED WORLD LPL ASSURE LAWYERS PROFESSIONAL LIABILITY INSURANCE POLICY INSURANCE
More informationAPPLICATION FOR TITLE AGENTS, ABSTRACTORS, AND ESCROW AGENTS ERRORS AND OMISSIONS LIABILITY INSURANCE
APPLICATION FOR TITLE AGENTS, ABSTRACTORS, AND ESCROW AGENTS ERRORS AND OMISSIONS LIABILITY INSURANCE Please complete this application in ink and answer all questions. An incomplete application cannot
More informationLAWYERS PROFESSIONAL LIABILITY INSURANCE RENEWAL APPLICATION
LAWYERS PROFESSIONAL LIABILITY INSURANCE RENEWAL APPLICATION Medmarc Casualty Insurance Company 14280 Park Meadow Drive Suite 300 Chantilly, VA 20151-2219 800.356.6886 703.652.1300 NOTICE: This professional
More informationLAWYERS PROFESSIONAL LIABILITY INSURANCE RENEWAL APPLICATION ADDENDUM
LAWYERS PROFESSIONAL LIABILITY INSURANCE RENEWAL APPLICATION ADDENDUM Name of Applicant Firm: Exp Policy #: Expiring Policy Date: RENEWAL CLIENTS WHO HAVE PREVIOUSLY COMPLETED APPLICATION: Please review
More informationGeneral Applicant Information
APPLICATION FOR LAWYERS PROFESSIONAL LIABILITY INSURANCE (CLAIMS-MADE FORM) General Applicant Information 1. Name of Firm: 2. Principal Address: 3. City: County: State: Zip Code: 4. Phone: Fax: 5. Does
More informationLaws Professional Liability Insurance Advantages and Disadvantages
APPLICATION FOR LAWYERS PROFESSIONAL LIABILITY INSURANCE POLICY (CLAIMS-MADE & REPORTED BASIS) **PREMIUM FINANCING AVAILABLE** Professional Liability Insurance Services, Inc.SM 8015 Bronco Lane, Suite
More informationAPPLICATION FOR EMPLOYED LAWYERS PROFESSIONAL LIABILITY INSURANCE
Executive Risk Management Associates 82 Hopmeadow Street Simsbury, Connecticut 06070-7683 APPLICATION FOR EMPLOYED LAWYERS PROFESSIONAL LIABILITY INSURANCE THIS APPLICATION IS FOR CLAIMS MADE AND REPORTED
More informationApplication. Professional Liability Insurance for Law Firms
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
More informationSpecified Professions Professional Liability Product
Specified Professions Liability Product SPECIFIED PROFESSIONS PROFESSIONAL LIABILITY APPLICATION This is an application for a claims made policy. Please read your policy carefully. SECTION I: BACKGROUND
More informationHow to Prepare a New York Defense Policy
St. Paul 1 st Choice SM For DRI Lawyers S St. Paul Fire and Marine Insurance Company Saint Paul, Minnesota IMPORTANT NOTE: This is an application for a policy, which, if issued, will be on a claims-made
More informationTitle Agents Professional Liability Application
1. Name of Applicant Address Phone Number Fax Number E-mail Address 2. Are there other office locations? Yes No If yes, please list (include county): 3. Applicant is: Sole Proprietor Partnership Corporation
More informationAtlantic Specialty Insurance Company (Stock company owned by the OneBeacon Insurance Group)
Atlantic Specialty Insurance Company (Stock company owned by the OneBeacon Insurance Group) EMPLOYED LAWYERS PROFESSIONAL LIABILITY INSURANCE APPLICATION NOTICE: THE POLICY FOR WHICH THIS APPLICATION IS
More informationACE Advantage. Employed Lawyers Professional Liability Application
ACE American Insurance Company Illinois Union Insurance Company Westchester Fire Insurance Company Westchester Surplus Lines Insurance Company ACE Advantage Employed Lawyers Professional Liability Application
More informationCasualty and Surety Company of America Hartford, Connecticut
Casualty and Surety Company of America Hartford, Connecticut SM LAWYERS PROFESSIONAL LIABILITY COVERAGE APPLICATION Important te: This is an application for a claims-made policy. To be covered, a claim
More informationSAFETY NET SHORT FORM INTERNET LIABILITY INSURANCE APPLICATION
Chubb Group of Insurance Companies 15 Mountain View Road, Warren, New Jersey 07059 Executive Risk Indemnity Inc. 2711 Centerville Road Suite 400, Wilmington, Delaware 19808 SAFETY NET SHORT FORM INTERNET
More informationLAWYERS PROFESSIONAL LIABILITY INSURANCE APPLICATION Colony Management Services 1-800-577-6614 FAX 804-327-1739
LAWYERS PROFESSIONAL LIABILITY INSURANCE APPLICATION Colony Management Services 1-800-577-6614 FAX 804-327-1739 1. Legal Name of Firm Business Address City State Zip County Telephone ( ) Fax ( ) 2. Individual
More informationProperty Managers Professional Package Product
COMMITTED TO A MAKING DIFFERENCE Property Managers Professional Package Product PROPERTY MANAGERS PROFESSIONAL PACKAGE PRODUCT APPLICATION All questions must be answered and application must be signed
More informationCity: County: State: Zip Code: Email address: Website: Business Phone:
APPLICATION FOR ACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE (CLAIMS-MADE BASIS) Insight Insurance 2000 S. Batavia Ave., Suite 300 Geneva, IL 60134 Toll Free Telephone (800) 447-4626 Telephone (630) 208-1900
More information1. Name of Firm:- 2. Principal Address: 3. City: County: State: Zip Code: 4. Phone: Fax:
APPLICATION FOR LAWYERS PROFESSIONAL LIABILITY INSURANCE (CLAIMS-MADE FORM) General Applicant Information 1. Name of Firm:- 2. Principal Address: 3. City: County: State: Zip Code: 4. Phone: Fax: 5. Does
More informationNational Union Fire Insurance Company of Pittsburgh, Pa. LAWYERS PROFESSIONAL LIABILITY RENEWAL APPLICATION
National Union Fire Insurance Company of Pittsburgh, Pa. (herein called the Insurer ) LAWYERS PROFESSIONAL LIABILITY RENEWAL APPLICATION NOTICE THIS IS AN APPLICATION FOR INSURANCE WRITTEN ON A CLAIMS
More informationEMPLOYMENT PRACTICES LIABILITY INSURANCE SUPPLEMENTAL APPLICATION
EMPLOYMENT PRACTICES LIABILITY INSURANCE SUPPLEMENTAL APPLICATION NOTICES: THE EMPLOYMENT PRACTICES LIABILITY COVERAGE PART/ENDORSEMENT PROVIDES THAT THE LIMIT OF LIABILITY AVAILABLE TO PAY JUDGMENTS OR
More informationProfessional Liability Errors and Omissions Insurance Application
Professional Liability Errors and Omissions Insurance Application PO Box 591 Plainview, NY 11803 T:(516) 396-4600 / F:(516) 396-4610 www.empirebrokerage.com tice: If coverage is issued, It will be based
More informationAPPLICATION FOR REAL ESTATE SERVICES PROFESSIONAL LIABILITY INSURANCE
APPLICATION FOR REAL ESTATE SERVICES PROFESSIONAL LIABILITY INSURANCE This is an Application for a claims made and reported policy. Please read the entire Application carefully before signing. Whenever
More informationACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE COVERAGE APPLICATION FORM CLAIMS MADE POLICY
ACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE COVERAGE APPLICATION FORM CLAIMS MADE POLICY Please answer each question completely. Please type or print clearly in ink. Please attach a copy of the firm s
More informationProfessional Liability Errors and Omissions Insurance Application
If coverage is issued, it will be on a claims-made basis. Notice: this insurance coverage provides that the limit of liability available to pay judgements or settlements shall be reduced by amounts incurred
More informationMISCELLANEOUS PROFESSIONAL LIABILITY AND PREMISES LIABILITY INSURANCE APPLICATION
MISCELLANEOUS PROFESSIONAL LIABILITY AND PREMISES LIABILITY INSURANCE APPLICATION THIS IS AN APPLICATION FOR CLAIMS-MADE AND REPORTED INSURANCE PROVIDED THROUGH HORIZON RISK INSURANCE, LLC. IT IS IMPORTANT
More informationSpecified Professions Professional Liability Product
COMMITTED TO A MAKING DIFFERENCE Specified Professions Liability Product SPECIFIED PROFESSIONS PROFESSIONAL LIABILITY APPLICATION This is an application for a claims made policy. Please read your policy
More informationGENERAL INFORMATION. Telephone Number: Fax Number: Email Address: Web Address:
1 st Choice Real Estate Services Professional Liability Coverage Application SM Travelers Casualty and Surety Company of America THE INFORMATION BEING REQUESTED IS FOR A CLAIMS MADE POLICY. IT IS IMPORTANT
More informationTHE HARTFORD DIRECTORS, OFFICERS AND ENTITY LIABILITY INSURANCE APPLICATION (FINANCIAL INSTITUTIONS/FINANCIAL SERVICES) NEW YORK
, a stock insurance company, herein called the Insurer THE HARTFORD DIRECTORS, OFFICERS AND ENTITY LIABILITY INSURANCE APPLICATION (FINANCIAL INSTITUTIONS/FINANCIAL SERVICES) NEW YORK NOTICE: THIS IS A
More informationGREAT AMERICAN ASSURANCE COMPANY Real Estate Professional Liability Insurance Application
GREAT AMERICAN ASSURANCE COMPANY Real Estate Professional Liability Insurance Application NOTICE: This is an application for a Claims-Made policy. Coverage for prior acts and claims made after termination
More informationPersonal Lines Insurance Agents Professional Liability
COMMITTED TO A MAKING DIFFERENCE Personal Lines Insurance Agents Professional Liability INSURANCE AGENTS AND BROKERS PROFESSIONAL LIABILITY APPLICATION All questions must be answered and application must
More informationCity: County: State: Zip Code:
APPLICATION FOR ACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE (CLAIMS-MADE BASIS) Insight Insurance 2000 S. Batavia Ave., Suite 300 Geneva, IL 60134 Toll Free Telephone (800) 447-4626 Telephone (630) 208-1900
More informationNavigators Insurance Company Real Estate Professionals Errors and Omissions Insurance Application
Navigators Insurance Company Real Estate Professionals Errors and Omissions Insurance Application NOTICE: This is an application for a Claims-made policy. Coverage for prior acts and claims made after
More informationReal Estate Claims-Made Professional Liability Insurance Application
Real Estate Claims-Made Professional Liability Insurance Application Application completion instructions. PLEASE DO NOT USE PENCIL Answer each question completely. If the question does not apply, print
More informationPersonal Lines Insurance Agents Professional Liability
Personal Lines Insurance Agents Professional Liability PART I - AGENCY DETAILS P.O. Box 2909 Jacksonville, FL 32203-2909 Phone: 800-342-2498 Fax: 904-355-7611 www.shellyins.com INSURANCE AGENTS AND BROKERS
More informationDeerfield Insurance Company - A Practical Application
Deerfield Insurance Company Evanston Insurance Company Essex Insurance Company Markel American Insurance Company Markel Insurance Company Associated International Insurance Company APPLICATION FOR SPECIFIED
More informationReal Estate Claims-Made Professional Liability Insurance Application
Real Estate Claims-Made Professional Liability Insurance Application Application completion instructions. PLEASE DO NOT USE PENCIL Answer each question completely. If the question does not apply, print
More information6. Number of employees including principals: Full-time Part-time Seasonal Total
Deerfield Insurance Company Evanston Insurance Company Essex Insurance Company Markel American Insurance Company Markel Insurance Company Associated International Insurance Company APPLICATION FOR SPECIFIED
More informationApplication Supplement for Collection Agency / Credit Bureau
Application Supplement for Collection Agency / Credit Bureau Please attach the following information: 1. Name of Applicant: 2. What measures are taken to assure compliance with the Fair Debt Collection
More information