PRO-FORM INSURANCE SERVICES LAWYERS EXCESS PROFESSIONAL LIABILITY INSURANCE NEW BUSINESS APPLICATION FORM THIS APPLICATION IS FOR COVERAGE ON A CLAIMS MADE AND REPORTED BASIS. PLEASE ANSWER ALL QUESTIONS COMPLETELY. THIS APPLICATION FORM AND ALL SUPPLEMENTS MUST BE SIGNED AND DATED BY A PARTNER OR AUTHORIZED PERSON OF THE ORGANIZATION. 1.(a) Name of Applicant: (Name of Applicant Firm must match firm s letterhead) Address of principal office of Applicant: Details of branch offices, if applicable: City: Province: Billings percentage: Please also list any branch office(s) outside of Canada and details of applicable billings. (d) (e) Date of Commencement of Business: Should coverage be required for former law firms, details of all such former firms: Firm name: Address: Dates in operation: Number of lawyers in practice: (f) Should coverage be required for for management companies of the Applicant, details of all such management companies: Management company name: Dates in operation: Services provided: 2. Number of Attorneys: Excluding of Counsel Of Counsel (Please complete attached Attorney Schedule) 3 Applicant Firm s gross income from the practice of law: Total Projected Fiscal Year Last Complete Fiscal Two Years Ago Year Fiscal Year End Dates / / / / / / Total Gross Receipts $. $. $.
4.(a) Main areas of Practice and percentage of last fiscal year s gross billable dollars: If the Applicant Firm is involved in any of the following areas of law please give details of the applicable percentage of the Applicant s total gross billings: Securities practice, including syndications/bonds/tax shelters/ limited partnerships and derivatives Intellectual property Plaintiff bodily injury Plaintiff medical malpractice Class action If any of the above are applicable, please provide details: 5.(a) What type of letters does your firm currently use? Engagement n-engagement Disengagement What type of Docket Control Systems does your firm currently use? Computer Tickler File Calendar Book Other Does your firm have a Conflict of Interest Avoidance System? If, is it Computerized? (d) How many suits for Fees have been filed by the Applicant Firm in last two years? 6.(a) Have any members of your firm been reprimanded, censured,suspended or disbarred within the past 5 years? If, please provide details: After enquiry of all owners, partners, shareholders, associates, employed lawyers, of counsel and employees, have any claims or suits been made in the past five years against the Applicant or any past or present owners, partners, shareholders, corporate officers, associates, employed lawyers, contract lawyers, of counsel or employees or its predecessors in business? If, please complete Supplement #2 in respect of each claim or suit.
After enquiry of all owners, partners, shareholders, associates, employed lawyers, of counsel and employees, are any persons aware of any circumstances, allegations, tolling agreements or contentions as to any incident which may result in a claim being made against the Applicant or any past or present owners, partners, shareholders, corporate officers, associates, employed lawyers, contract lawyers, of counsel or employees or its predecessors in business. If, please complete Supplement #2 in respect of each incident. (d) Have all claims or circumstances requiring a response in questions 6. (a) and 6. been reported to and accepted by a current or past insurer? If, please provide details: (e) Has the Applicant Firm ever had a Professional Liability policy declined, cancelled or non-renewed by the Insurer for any reason? If, please provide details: NOTE: THIS POLICY WILL NOT COVER ANY CLAIM OR CIRCUMSTANCE STATED IN THE APPLICATION, ADDENDUM OR ANY ACT, ERROR, OMISSION OR CIRCUMSTANCE WHICH COULD GIVE RISE TO A CLAIM, OF WHICH THE APPLICANT HAS KNOWLEDGE PRIOR TO THE INCEPTION OF THE POLICY. 7.(a) Most recent Professional Liability Coverage: Retroactive Date: Insurer(s) Limit of Liability Desired Limit of Excess Professional Liability Insurance: $1,000,000 Each Claim/Aggregate $2,000,000 Each Claim/Aggregate $3,000,000 Each Claim/Aggregate $4,000,000 Each Claim/Aggregate $9,000,000 Each Claim/Aggregate $14,000,000 Each Claim/Aggregate $19,000,000 Each Claim/Aggregate $24,000,000 Each Claim/Aggregate $29,000,000 Each Claim/Aggregate $,000,000 Each Claim / $,000,000 Aggregate te: The limits will be in excess of the $1,000,000 each claim provided by LawPro, other Canadian Law Society Compulsory Program, or any other specific insurance arranged if agreed by Excess Insurer(s). Do you wish to apply for Outside Directors Liability Coverage or Employment Practices Liability Coverage? 8. Declarations and Acknowlegments: Please note that the limit of excess insurance coverage applies for the law firm and that the excess insurance policy limit applies in respect of all claims reported by all of those insured under the excess insurance policy.
The limit of excess insurance policy includes costs, charges and expenses incurred in connection with any claim and, therefore, the amount of insurance available under the excess insurance policy for the payment of damages shall be reduced and may be completely exhausted by the payment of costs, charges and expenses. Coverage is available under the excess insurance policy for vicarious liability in excess of the innocent party sub-limit contained within the LawPRO primary coverage. When indications are provided for the excess insurance policy they will also include an optional indication of the cost for vicarious liability in excess of the innocent party sub-limit. Please attach with this application form a copy of the current letterhead of the Applicant and a copy of the the current letterhead of management company listed in the answer to question 1.(f). The Applicant declares and warrants that, after enquiry, to the best knowledge of all persons to be insured the statements set forth herein and in any attachments made hereto are true and no material facts have been supressed, omitted or misstated. Underwriters reserve the right to deny or rescind coverage on any policy that is issued as a result of this application if, in the statements set forth herein and in any attachments made hereto it is found that material information has been omitted, supressed or misstated. Underwriters also reserve the right to amend the terms, conditions and coverage of any policy that is issued as a result of this application if, subsequent to the date of this application, but prior to the inception date of such policy, there are any material alterations to the information contained herein. In the event of such material alteration, as aforesaid, the Applicant agrees to give immediate written notice to Underwriters and such notice shall attach to and form part of this application. Signing this application does not bind the Applicant or Underwriters to complete the insurance, but it is agreed that the statements and particulars contained herein will be relied upon by Underwriters should a policy be issued. This application is signed on behalf of the Applicant and others on whose behalf this application is submitted. DATE SIGNATURE OF PARTNER OR NAMED APPLICANT APPLICANT FIRM NAME
List the names of all lawyers that work on behalf of the firm. ATTORNEY SCHEDULE Name Year joined Firm Year of Admission to Bar Designation* CLE in Last 12 Months Y/N Average hours worked per week YES * "O" Owner/Officer/Director/Shareholder "P" Partner of a Partnership "E" Employed Lawyer of Applicant "OC" Of Counsel Lawyer of Applicant "RP" Retired Partner of Applicant "S" Sole Proprietor
CLAIM AND INCIDENT SUMMARY THIS FORM IS TO BE COMPLETED BY THE APPLICANT FOR EACH CLAIM OR INCIDENT IF IT HAS BEEN REPORTED AFTER JANUARY 1, 2008. COMPLETE A SEPARATE FORM FOR EACH SUCH CLAIM OR INCIDENT (PHOTOCOPY THIS FORM AS NECESSARY). IF SPACE IS INSUFFICIENT TO ANSWER ANY QUESTIONS FULLY, USE REVERSE SIDE OF THIS PAGE OR ATTACH A SEPARATE SHEET. 1. (a) Name of Lawyer involved in claim/incident: Law Firm of Lawyer at time of (alleged) error: 2. Date of (alleged) claim/incident: 3. Date reported to Law Society and/or Excess Insurer(s): 4. State if a claim has been made, or if the matter is an incident that has been reported in case a claim develops later. The matter reported is: an incident a claim Status is: open in suit closed Amount Paid $. NOTE: A "CLAIM" IS A DEMAND EITHER ORALLY OR IN WRITING (INCLUDING A SUIT) MADE BY A PARTY FOR COMPENSATION OR HOLDING A LAWYER RESPONSIBLE FOR A LOSS. AN "INCIDENT" IS AN ERROR OR OMISSION, WHICH A LAWYER IS AWARE OF AND WHICH COULD REASONABLY BE EXPECTED TO BE THE BASIS OF A CLAIM OR SUIT. 5. (a) If the matter is a claim that is open or in suit, please complete the following: Name of claimant(s) Additional defendants, if any Amount demanded in Pleadings $ Claimant's settlement demand $ Defendant's offer for settlement $ Insurers' loss reserve (if known) $ For open claim or incident provide your estimate of damages: $ For this open claim or incident provide your estimate of the likelihood of liability: Unlikely Possible Probable Definite 6. Area of law giving rise to (alleged) error or omission: 7. Brief Description of claim/incident: SIGNATURE OF AUTHORISED APPLICANT TITLE Date