• Lawyers Mutual Insurance
  • Lawyers Mutual Insurance
  • Lawyers Mutual Insurance
New Admitee Application

GENERAL INFORMATION
*Name of Firm:
Required
*Desired Effective Date:
Required
*Type:
Required
Other, explain:
Invalid Input
*Address:
Required
*County:
Required
*Year Practice Established:
Required
*City:
Required
*State:
Invalid Input
*Zip:
Required
*Inside City Limits:
Required
*Telephone:
xxx-xxx-xxxx
Fax:
xxx-xxx-xxxx
*E-mail:
Required
*Number if Lawyers to be Insured:
Required
Number of Non-Lawyer Employees:
Invalid Input

*Does your firm share its office or expenses with any other attorney, law firm, or organization?
Required
*Does your firm and any such person or organization share the same letterhead?
Required
*Is there a work-for-space arrangement?
Required
*If the other organization is a firm of lawyers, are there any case sharing arrangements?
Required
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.
Invalid Input

  Lawyer 1 Lawyer 2 Lawyer 3
Lawyer Name:
Invalid Input
Invalid Input
Invalid Input
KY Bar Admit Number:
Invalid Input
Invalid Input
Invalid Input
KY Bar Admit Date:
Invalid Input
Invalid Input
Invalid Input
License in Other States Y/N: *If yes, denote state(s), bar admit date(s), bar number(s) and % of business
Invalid Input
Invalid Input
Invalid Input
Position in Firm:
Invalid Input
Invalid Input
Invalid Input
Incidental Practice Y/N: *If yes, denote hours per week
Invalid Input
Invalid Input
Invalid Input
*Would any lawyer be serving as a director, officer, trustee, partner or employee of a client?
Required
*If yes: Name of lawyer, client, & position served:
Invalid Input
*Do you plan to use new client screening procedures to review fees, case merit, or client attitude prior to accepting a case?
Required
*Will you be using formal engagement, nonengagement, and disengagement letters?
Required
*Do you have a planned system for docket/calendar control?
Required
Who will make the initial entries in the system?
Invalid Input
Will statute of limitations and procedural deadlines be noted in the system?
Invalid Input
Do you plan to develop a weekly work schedule listing key deadlines and completion dates?
Invalid Input
*Provide the name of a mentor lawyer you would contact if guidance on a case matter was needed:
Invalid Input
*Available Limits of Liability (Per Claim/Annual Aggregate):
Required
*Per Claim Deductibles:
Required
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.

Please Enter Code Below:
Capcha
  Refresh
Required
  

 

323 West Main Street, Suite 600  |  Louisville, KY 40202  |  Ph. 502-568-6100  |  Fax 502-568-6103

Disclaimer: The contents of this Web site are intended for general information purposes only and should not be construed as legal advice or legal opinion on any specific facts or circumstances. It is not the intent of this Web site to establish an attorney’s standard of due care for a particular situation. Rather, it is our intent to advise our policyholders to act in a manner which may be well above the standard of due care in order to avoid claims having merit, as well as those without merit. In the event any statement on the Web site differs from a statement in an issued policy the policy will control.

Produced and Maintained by Scarnegie Interactive, LLC