Questionnaire for Premium Indicator from Lawyers Mutual
This application will provide an estimate for insurance. To receive a binding quotation you must complete the main application.
Note:These fields are REQUIRED

Regarding the Firm:
First Name:
Middle Initial:
Last Name:
Name of Firm:
Address:
County:
City:
State:
Zip:
Telephone
Fax:
E-mail Address:
Policy Effective Date:


Please complete for Lawyer 1:
Full Name:
KY Bar Admit Date:
KY Bar Number:
Received 20 CLE Credits in Preceeding Year? Yes    No
Part Time / Hours per Week 1-10 hrs    11-20 hrs    21-30 hrs    31-40 hrs

Please complete for Lawyer 2:
Full Name:
KY Bar Admit Date:
KY Bar Number:
Received 20 CLE Credits in Preceeding Year? Yes    No
Part Time / Hours per Week 1-10 hrs    11-20 hrs    21-30 hrs    31-40 hrs

Please complete for Lawyer 3:
Full Name:
KY Bar Admit Date:
KY Bar Number:
Received 20 CLE Credits in Preceeding Year? Yes    No
Part Time / Hours per Week 1-10 hrs    11-20 hrs    21-30 hrs    31-40 hrs

Please complete for Lawyer 4:
Full Name:
KY Bar Admit Date:
KY Bar Number:
Received 20 CLE Credits in Preceeding Year? Yes    No
Part Time / Hours per Week 1-10 hrs    11-20 hrs    21-30 hrs    31-40 hrs

Please complete for Lawyer 5:
Full Name:
KY Bar Admit Date:
KY Bar Number:
Received 20 CLE Credits in Preceeding Year? Yes    No
Part Time / Hours per Week 1-10 hrs    11-20 hrs    21-30 hrs    31-40 hrs


Select your Available Limit of Liability. (Per Claim / Annual Aggregate):
Select the Type of Deductible:
Select your Deductible Amount:
Current Carrier:
Dates you have been continuously insured:
Expiration date:
Premium:
Limits & Deductible:


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:

Claims History:
Have you or any lawyer in the Firm had or reported any claim(s) in the last seven years: No    Yes
Claim 1, Date Reported
Claim 1, Amount Paid
Claim 1, Describe Claim
Claim 2, Date Reported
Claim 2, Amount Paid
Claim 2, Describe Claim
Claim 3, Date Reported
Claim 3, Amount Paid
Claim 3, Describe Claim

The applicant declares that to the best of the knowledge and belief of all persons in the Firm 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 Lawyers Mutual Insurance Company of Kentucky. Signing this application does not bind the Firm 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, Lawyers Mutual Insurance Company of Kentucky must give the Firm 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.

Our Office

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

Contact Us
Get Directions

Upcoming Seminars

View full calendar

Most Popular

Recent News