Application for Professional Liability Insurance
( Page 1 of 5 )

The following is for claims-made lawyers professional liability insurance. A claims made policy applies only to claims first made during the policy period or any extended reporting period. The limit of liability available to pay damages will be reduced and may be exhausted by claims expenses and claims expenses will be applied against the deductible amount.

Note:These fields are REQUIRED

Regarding the Firm:
Name of the Firm:
Type of Firm:
Present policy expiration date
(or effective date desired if no prior coverage):
Year Firm established:
Address:
County:
City:
State:
Zip:
Branch office address if applicable:
Are you inside the city limits? Yes    No
Telephone:
Fax:
Primary contact:
E-mail address:
Total number of lawyers in Firm:
Total number of non-lawyers in Firm:

What percentage of time, not income, do you spend in the following practice areas? Must equal 100%
Admiralty: % Domestic Relations / Family Law: % Money Management: %
Anti-Trust / Trade Regulations.: % Entertainment Law: % Municipal Law: %
Banking: % Environmental Law: % Natural Resources: %
Bankruptcy: % Equine Law: % Private Placement Memorandum: %
BI / PI Defendants: % Estate Planning / Trust: % Public Utilities: %
BI / PI Plaintiffs: % Estate Probate / Adminstration: % Real Estate: %
Class Action / Mass Tort: % Foreign Practice: % Securities (S.E.C.): %
Collection / Repossession: % Immigration Law: % Social Security / Disability: %
Communications: % International Law: % State Law Securities: %
Copyright / Patent / Trademark: % Labor / Employment Law: % Taxation: %
Corporate / Business Organization: % Litigation (General Civil): % Workers Compensation / Defendants: %
Criminal: % Mediation / Arbitration: % Workers Compensation / Plaintiffs: %
Other; Please Describe:

Select your Available Limit of Liability. (Per Claim / Annual Aggregate):
Select the Type of Deductible:
Select your Deductible Amount:
Indicate the Firm's annual gross billing category for the fiscal year preceding this applications date:
Does 10% or more of the Firm's working hours come from one client account or a group or related accounts? Yes    No
Please describe the type of services provided and your relationship with client.


 
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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