New Admittee Application for Lawyers Professional Liability Insurance
This application is only for those lawyers in the first year of law practice.
Note:These fields are REQUIRED

Regarding the Firm:
Name of the Firm:
Year Practice Established:
Address:
County:
City:
State:
Zip:
Are you inside the city limits? Yes    No
Telephone:
Fax:
E-mail Address:

Type of Firm insuring:
Desired effective date:
Number of Lawyers to be insured:
Number of Non-Lawyers to be insured:

Does the Firm share its office or expenses with any other lawyer, law firm, or organization? Yes    No
Does the Firm and any such person or organization share the same letterhead? Yes    No
Is there a work-for-space arrangement? Yes    No
If the other organization is a firm of lawyers, are there any case sharing arrangements? Yes    No
If yes, indicate the carrier and amount of professional liability insurance carried by such organization and describe any contractual arrangement that would affect the applicant’s liability in the event of a claim with respect to such case sharing arrangement.


Please complete for Lawyer 1:
Full Name:
KY Bar Admit Date:
KY Bar Number:
Position in Firm:
Incidental Practice?
Yes    No
No. hours per week:
Licensed in Other States? Yes    No
Please denote state(s), bar admit date(s),
bar number(s) and % of business

Please complete for Lawyer 2:
Full Name:
KY Bar Admit Date:
KY Bar Number:
Position in Firm:
Incidental Practice?
Yes    No
No. hours per week:
Licensed in Other States? Yes    No
Please denote state(s), bar admit date(s),
bar number(s) and % of business

Please complete for Lawyer 3:
Full Name:
KY Bar Admit Date:
KY Bar Number:
Position in Firm:
Incidental Practice?
Yes    No
No. hours per week:
Licensed in Other States? Yes    No
Please denote state(s), bar admit date(s),
bar number(s) and % of business


Would any lawyer be serving as a director, officer, trustee, partner or employee of a client? Yes    No
Please list name of lawyer, client, & position served:

Do you plan to use new client screening procedures to review fees, case merit,
or client attitude prior to accepting a case?		 Yes    No
Will you be using formal engagement, nonengagement, and disengagement letters? Yes    No
Provide the name of a mentor lawyer you would contact if guidance on a case matter was needed:
Do you have a planned system for docket/calendar control? Yes    No
Who will make the initial entries in the system?
Will statute of limitations and procedural deadlines be noted in the system? Yes    No
Do you plan to develop a weekly work schedule listing key deadlines and completion dates? Yes    No


Select your Available Limit of Liability. (Per Claim / Annual Aggregate):
Select your Per Claim Deductible:


The applicant declares that to the best of the knowledge and belief of all persons to be insured that the information provided herein and any attachments made hereto are true and no material facts have been misstated or withheld. The information provided in this application shall be the basis of the policy of insurance and deemed incorporated therein.

The applicant understands that any misrepresentation or false statement on this application or attachments may result in loss of coverage under any policy issued by the Lawyers Mutual Insurance Company of Kentucky. Signing this application does not bind the Applicant or Lawyers Mutual Insurance Company of Kentucky to issue the policy of insurance. The undersigned is authorized to sign this application on behalf of all persons to be insured.

In accordance with KRS 304.47-030, we must give you the following notice in your application for insurance. 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.

IMPORTANT REMINDER: Report any claims made against you or incidents that might result in a claim during your current policy term to your present insurance company before the policy expires. Failure to do so may result in a loss of coverage.

Please enter the verification code below and click submit:
  
Please note that all required fields must be entered in order to submit your application. You may need to scroll through the application to see which required fields you've missed.

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Lawyers Mutual Insurance
Company of Kentucky
Waterfront Plaza
323 West Main Street,
Suite 600
Louisville, KY 40202
KY Wats 1-800-800-6101
Ph. 502-568-6100
Fax 502-568-6103

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