• Lawyers Mutual Insurance
  • Lawyers Mutual Insurance
  • Lawyers Mutual Insurance

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Complete Application

APPLICATION FOR LAWYERS PROFESSIONAL LIABILITY INSURANCE
*Available Limits of Liability - Per Claim/Annual Aggregate:









Required
*Available Deductibles:









Required
Present policy expiration date (or effective date desired if no prior coverage):
Required
Other:
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GENERAL INFORMATION
1. *Name of Firm:
Required
*Type:
Required
Other:
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2. *Primary Contact:
Required
3. Year Firm Established:
Required
4. *Address:
Required
*City:
Required
*State:
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*Zip:
Required
Within City Limits:
Required
5. *Phone:
required
Fax:
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*Primary Contact Email:
Required
6. Branch Office Address, if applicable:
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7. *Total Number of Lawyers in Firm:
Required
8. Total Number of Non-Lawyer Employees:
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PRACTICE AREAS
What percentage of time, not income, do you spend in the following practice areas? Total must equal 100
Admiralty:
Numbers only.
Foreign Practice:
Numbers only.
Anti-Trust/Trade Regulations:
Numbers only.
Immigration Law:
Numbers only.
Banking:
Numbers only.
International Law:
Numbers only.
Bankruptcy:
Numbers only.
Labor/Employment Law:
Numbers only.
BI/PI Defendants:
Numbers only.
Litigation (General Civil):
Numbers only.
BI/PI Plaintiffs:
Numbers only.
Mediation/Arbitration:
Numbers only.
Class Action/Mass Tort:
Numbers only.
Money Management:
Numbers only.
Collection/Repossession:
Numbers only.
Municipal Law:
Numbers only.
Communications:
Numbers only.
Natural Resources:
Numbers only.
Copyright/Patent/Trademark: Private Placement Memorandum:
Numbers only.
Corporate/Business Organization:
Numbers only.
Public Utilities:
Numbers only.
Criminal:
Numbers only.
Real Estate:
Numbers only.
Domestic Relations/Family Law:
Numbers only.
Securities (S.E.C):
Numbers only.
Entertainment Law:
Numbers only.
Social Security/Disability:
Numbers only.
Environmental Law:
Numbers only.
State Law Securities:
Numbers only.
Equine Law:
Numbers only.
Taxation:
Numbers only.
Estate Planning/Trust:
Numbers only.
Workers Compensation/Defendants:
Numbers only.
Estate Probate Administration:
Numbers only.
Workers Compensation/Plaintiffs:
Numbers only.
Other, Please Describe:
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10. *Indicate the Firm’s annual gross billing category for the fiscal year preceding this application’s date:
Required
11. *Does 10% or more of the Firm’s working hours come from one client account or a group of related client accounts?
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If yes, please describe the type of services provided and your relationship with client.
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LAWYERS
12. Lawyer 1
*Name:
Required
*Email:
Required
*Position in Firm:
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*KY Bar Admit Date:
Required
*KY Bar Admit Number:
Required
*License in Other State(s):
Required
If yes, denote state(s), bar admit date(s), bar number(s) and % of business:
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*Part Time:
Required
If yes, why:
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If yes, denote hours per week:
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*Incidental Practice:
Required
If yes, denote hours per week:
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*Public Official:
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If yes, describe position & denote if you want coverage:
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*Entered into any contract or agreement, oral or written, guaranteeing the result of any professional service rendered by him/her or any person under his/her supervision:
Required
If, yes explain circumstances:
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*Treated for alcohol or substance abuse:
Required
If yes, provide a course of treatment:
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*Convicted or pleaded guilty or no con- test to criminal offense involving moral turpitude or which constitutes a felony:
Required
If yes, explain circumstances:
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*Serving as a director, officer, trustee, partner, or employee of any client:
Required
If yes, name the client and the position served:
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*Have any fiduciary responsibility to or possess any ownership in any client:
Required
If yes, name of the client:
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*Received 20 CLE Credits in Preceding KBA Year:
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Lawyer 2
Name:
Required
Email:
Required
Position in Firm:
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KY Bar Admit Date:
Required
KY Bar Admit Number:
Required
License in Other State(s):
Required
If yes, denote state(s), bar admit date(s), bar number(s) and % of business:
Invalid Input
Part Time:
Required
If yes, why:
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If yes, denote hours per week:
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Incidental Practice:
Required
If yes, denote hours per week:
Invalid Input
Public Official:
Invalid Input
If yes, describe position & denote if you want coverage:
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Entered into any contract or agreement, oral or written, guaranteeing the result of any professional service rendered by him/her or any person under his/her supervision:
Required
*If, yes explain circumstances:
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Treated for alcohol or substance abuse:
Required
If yes, provide a course of treatment:
Invalid Input
Convicted or pleaded guilty or no con- test to criminal offense involving moral turpitude or which constitutes a felony:
Required
If yes, explain circumstances:
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Serving as a director, officer, trustee, partner, or employee of any client:
Required
If yes, name the client and the position served:
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Have any fiduciary responsibility to or possess any ownership in any client:
Required
If yes, name of the client:
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Received 20 CLE Credits in Preceding KBA Year:
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Lawyer 3
Name:
Required
Email:
Required
Position in Firm:
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KY Bar Admit Date:
Required
KY Bar Admit Number:
Required
License in Other State(s):
Required
If yes, denote state(s), bar admit date(s), bar number(s) and % of business:
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Part Time:
Required
If yes, why:
Invalid Input
If yes, denote hours per week:
Invalid Input
Incidental Practice:
Required
If yes, denote hours per week:
Invalid Input
Public Official:
Invalid Input
If yes, describe position & denote if you want coverage:
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Entered into any contract or agreement, oral or written, guaranteeing the result of any professional service rendered by him/her or any person under his/her supervision:
Required
*If, yes explain circumstances:
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Treated for alcohol or substance abuse:
Required
If yes, provide a course of treatment:
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Convicted or pleaded guilty or no con- test to criminal offense involving moral turpitude or which constitutes a felony:
Required
If yes, explain circumstances:
Invalid Input
Serving as a director, officer, trustee, partner, or employee of any client:
Required
If yes, name the client and the position served:
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Have any fiduciary responsibility to or possess any ownership in any client:
Required
If yes, name of the client:
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Received 20 CLE Credits in Preceding KBA Year:
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Lawyer 4
Name:
Required
Email:
Required
Position in Firm:
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KY Bar Admit Date:
Required
KY Bar Admit Number:
Required
License in Other State(s):
Required
If yes, denote state(s), bar admit date(s), bar number(s) and % of business:
Invalid Input
Part Time:
Required
If yes, why:
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If yes, denote hours per week:
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Incidental Practice:
Required
If yes, denote hours per week:
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Public Official:
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If yes, describe position & denote if you want coverage:
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Entered into any contract or agreement, oral or written, guaranteeing the result of any professional service rendered by him/her or any person under his/her supervision:
Required
*If, yes explain circumstances:
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Treated for alcohol or substance abuse:
Required
If yes, provide a course of treatment:
Invalid Input
Convicted or pleaded guilty or no con- test to criminal offense involving moral turpitude or which constitutes a felony:
Required
If yes, explain circumstances:
Invalid Input
Serving as a director, officer, trustee, partner, or employee of any client:
Required
If yes, name the client and the position served:
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Have any fiduciary responsibility to or possess any ownership in any client:
Required
If yes, name of the client:
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Received 20 CLE Credits in Preceding KBA Year:
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FIRM HISTORY
13. List the names of all firms of which the assets and liabilities of the former firm have been acquired by your firm.
  Name of Firm Name of Firm Name of Firm
 
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Year Established
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Number of Lawyers
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14. Has the name of your Firm changed within the past five years?
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If yes, list the name(s) of firms used.
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MANAGEMENT OF THE FIRM
15. If you are a sole practitioner, you must provide the name of the lawyer(s) with whom you have an agreement to be responsible for your practice when you are absent for an extended period of time (eg., vacation, illness, etc.).
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16. *Does the Firm share its office or expenses with any other lawyer, law firm, or organization?
Required
A. *Does the Firm and any such person or organization share the same letterhead?
Required
B. *Is there a work-for-space arrangement?
Required
C. *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.
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17. *Does the Firm maintain a conflict of interest screening system?
Required
If yes, what methods are employed?
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18. *Are any procedures in place to ensure that a lawyer is not overloaded with work?
Required
If yes, explain:
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19. *Does the Firm use a formal or informal new client screening procedure to review fees, case merit, or client attitudes prior to case acceptance?
Required
20. *Does the new client screening procedure include formal engagement, non-engagement, and disengagement letters?
Required

OTHER INFORMATION
21. Please indicate whether the Firm is engaged in any of the following activities by checking “yes” or “no”. If yes, please indicate the percentage of total working hours devoted to each activity and whether or not separate professional liability insurance is carried for this work.
NOTE: If yes, to “Title Abstractor” and/or “Title Agent” below, complete the Real Estate & Financial Institutions Supplemental Application A.
Type of Activity Total Working Hours Devoted to Each Professional Insurance Carrier Expiration Mo/Day/Year
*Insurance Agent:
Required
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*Accountant:
Required
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*Real Estate Broker:
Required
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*Title Abstractor:
Required
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*Title Agent:
Required
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22. *Is the Firm involved with any Securities and Exchange Commission work? NOTE: If yes, please complete the SEC Supplemental Application Form B.
Required
23. *Is the Firm involved with any mass tort or class action cases? NOTE: If yes, please complete the BI/PI Supplemental Application Form C.
Required

TIME DOCKET AND RECORD CONTROL SYSTEMS
24. *Does the Firm use a formal system for record retention and control?
Required
A. *Does the system used identify how long records should be maintained?
Required
B. *Does the file system used separate inactive files from active files?
Required
C. *Are inactive files closed and archived on a regular schedule?
Required
D. *Are archived files destroyed after a certain number of years?
Required
If yes, for how many years:
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25. *Do you have a written policy for the operation of the Firm time/docket control system?
Required
26. *Does each attorney in the Firm understand and use the time/docket control system?
Required
27. *Is the Firm’s time/docket control system:
Required
28. *Does the Firm’s time/docket control system provide that all dates be entered immediately?
Required
29. *Does the Firm’s time/docket control system note statutes of limitations and procedural deadlines?
Required
30. *Do the Firm’s employees enter all appointments on the Firm’s time/docket control system, to include other personal and professional commitments?
Required
31. *Does the Firm’s time/docket control system have a procedure for verification of the completion of docketed events?
Required
32. *Are the Firm’s time/docket control system records maintained in a central location in the office?
Required
33. *Does the Firm’s time/docket control system use more than one independent control (e.g., attorney and secretary each maintain a calendar of the attorney’s commitments)?
Required
34. *Does one person in the Firm have primary responsibility for the operation of the time/docket control system?
Required
35. *Is there a person with secondary responsibility who can maintain and explain the time/docket control system if the primary person is absent for an extended period of time?
Required
36. If question(s) 24 - 35 are not applicable, please provide an explanation:
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CLAIMS
37. *Within the past seven years, has any professional liability claim been asserted, action filed, or claim paid against the current Firm, predecessor Firm, or a lawyer listed in Question 12?
NOTE: If yes, complete a Claim Report Form (Supplemental Application Form D) for each such claim or action.
Required
38. *Has any lawyer listed in Question 12 ever been reprimanded, censured, disciplined by, refused admission to practice, disbarred, or suspended (including voluntary suspension) from practice by any bar association, court, administrative, or regulatory agency?
Required
If yes, please explain circumstances:
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39. *Does any lawyer listed in Question 12 know of any present or prior incident, error, act, or omission which could result in a professional liability claim against the Firm or any lawyer listed in Question 12 or Firm listed in Question 14?
NOTE: If yes, complete Claim Report Form (Supplemental Application Form D) and attach a copy of the notice that was sent to the insurance carrier involved.
Required
40. *Has any lawyer listed in Question 12 or any Firm listed in Question 14 had any insurance company cancel, decline, or refuse to renew professional liability insurance?
Required
If yes, please explain circumstances:
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PREVIOUS INSURANCE
41. *Has any lawyer listed in Question 12 or Firm listed in Question 14 ever been insured by another carrier?
NOTE: If yes, please list lawyers professional liability insurance carrier for each of the past seven years. If insurance history is not provided, prior acts will not be quoted.
Required
Insurer Name Policy Number Limits of Liability Deductible (if any) Policy Period Coverage Basis
(Claims Made/Occurrence)
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OTHER INFORMATION
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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 a policy of insurance.
SUPPLEMENTAL APPLICATION FORM A; REAL ESTATE & FINANCIAL INSTITUTIONS
If the Firm does no Real Estate work, select 'N/A':
Required

REAL ESTATE
1. What percentage of the Firm’s real estate practice is devoted to: (Total must equal 100):
A. Residential (1-4 family units):
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B. Commercial:
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2. What percentage of the Firm’s real estate practice is devoted to: (Total must equal 100):
A. Title Work/Closings:
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D. Limited Partnerships/Syndications:
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B. Landlord/Tenant:
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E. Condominium Formation/Conversions:
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C. All other:
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3. What is the approximate number of closings and title work assignments performed annually by the Firm?
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  Average Property Value Range in Value (Low/High) Number
A. Residential
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B. Commercial
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4. When the Firm is conducting or attending a closing and is holding the closing funds for disbursement, who prepares and/or signs the checks for disbursement?
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Identify OTHER:
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5. When the Firm is conducting a closing and is responsible for completing the HUD forms and/or disbursing the funds, who signs the HUD forms and disburses the checks for the expenses such as fees, taxes, mortgages, liens, etc. required by HUD to be paid?
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Identify OTHER:
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6. In questions 4 and 5, does the Firm ever delegate to anyone, who is not an employee or member of the Firm, any responsibility for preparing the checks, disbursing them, and/or signing the HUD forms?
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If yes, please describe the circumstances and who is allowed to do so:
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7. When the Firm examines title to real estate and/or issues title opinions, the actual examination is done by: (Check all that apply):
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Please describe the training and experience of all non-lawyer employees and/or third parties/Independent contractors doing title examinations for the Firm:
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8. Does the Firm outsource title examinations to non-lawyer entities such as title examiners, freelance paralegals, or others?
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Name & Approximate Number:
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9. Does the Firm obtain and update proof that these individuals or entities (listed in question 8) have and maintain errors and omissions insurance in case they make a mistake?
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  If yes, Number Done Annually
10. Does the Firm’s real estate practice include limited partnership formation?
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11. Does the Firm’s real estate practice include syndications?
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12. Does the Firm’s real estate practice include providing opinions for limited partnership formation or syndication?
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FINANCIAL INSTITUTIONS
13. Identify all financial institutions any lawyer in the Firm has represented in the past five years and the type of work performed for each:
Name of Institution Type of Work Performed
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14. If the Firm does foreclosures, does another lawyer in the Firm attend the foreclosure sale, or does the Firm assign this task to local counsel if out of the Firm’s immediate area?
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A. *If other counsel is obtained, does the Firm obtain proof of the other counsel’s malpractice coverage to protect the Firm in the event the other counsel misses the sale or fails to properly carry out instructions?
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15. During the past five years has any lawyer represented any financial institution which has become insolvent?
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Name of Lawyer Financial Institution Position Held
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16. Is any lawyer in the Firm a director or officer in any financial institution or does any lawyer own, personally or beneficially,
five percent or more of the stock in any financial institution?
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Name of Lawyer Financial Institution Position Held
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17. Does any lawyer serve on a loan committee or act as general counsel for a financial institution?
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Name of Lawyer Financial Institution Position Held
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18. If the answer to Question 16 or 17 is yes as to any lawyer in the Firm, does that lawyer serve as a member of such loan committee or as general counsel or provide advice or opinion with respect to legal lending limits or the quality of collateral?
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19. Does any lawyer perform legal work for both the borrower and the financial institution simultaneously with respect to any real estate transactions?
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If yes, what steps are taken to avoid a conflict of interest?
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20. Does the Firm or any attorney own a title company?
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If yes, please denote the name of the title company?
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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 a policy of insurance.
SUPPLEMENTAL APPLICATION FORM B; SECURITIES & EXCHANGE COMMISSION
*If the Firms does no SEC work, select 'N/A':
Required

CAPACITY ALLOCATION
1. Bond Counsel
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2. Private Placement:  
A. as counsel for underwriters:
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B. as counsel for issuer:
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C. as counsel for security holder(s):
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3. Public Offerings of Securities:  
A. Securities registered under the Securities Act of 1933:  
1) as counsel for underwriters:
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2) as counsel for issuer:
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3) as counsel for security holder(s):
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B. Offerings exempt from registration under the Securities Act of 1933:  
1) as counsel for underwriters:
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2) as counsel for issuer:
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3) as counsel for security holder(s):
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C. Does the Firm prepare, review, approve, or take part in the drafting of any private placement memorandum?:
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4. Representing clients as to compliance with proxy requirements (other than in mergers) and reporting requirements under Securities Exchange Act of 1934:
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5. Takeovers and other acquisitions of publicly held companies (including roles as special local counsel):  
A. where client was bidder or acquiring company in contested acquisition:
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B. where client was bidder or acquiring company in friendly acquisition:
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C. where client was target company in contested acquisition:
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D. where client was target company in friendly acquisition:
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6. Securities (judicial or administrative):
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7. Other (please describe):
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8. What steps does the Firm take to satisfy “due diligence” requirements under Federal and State Securities acts?
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9. Has the Firm (including any predecessor Firms), or any present partner of the Firm (or any of its predecessor Firms), been subject to any disciplinary proceeding before the SEC or State Securities authorities within the past ten years?
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10. Is the Firm representing any client in any litigation in which the issues involve any Federal or State Securities work handled by the Firm (including the adequacy of registration statements, official statements, proxy statements, or tender offer documents)?
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11. Do any partners of the Firm serve as directors or officers of corporations that are clients of the Firm and which have publicly held securities outstanding?
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Name of Lawyer Corporation Position Held
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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 a policy of insurance.
SUPPLEMENTAL APPLICATION FORM C; CLASS ACTION/MASS TORT
*If the Firms does no Class Action/Mass Tort work, select 'N/A':
Required

OTHER INFORMATION
Name of Law Firm:
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1. Please complete the following for all attorneys in the Firm who are involved in class action/mass tort suits plaintiff or defense.
Name of Lawyer Number of Years Litigation Experience Number of Fees less than $50,000 Number of Fees more than $50,000
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2. What is the average dollar amount of awards, judgments, and settlements in class action/ mass tort cases handled by the Firm?
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3. What percentage of claims/suits that you handled each year are concluded by: (Total must equal 100)
A. Settlement prior to filing suit:
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B. Settlement after suit:
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C. Trial/Verdicts:
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D. Other:
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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 a policy of insurance.
SUPPLEMENTAL APPLICATION FORM D; CLAIM REPORT FORM
*If the Firms has no Claim Reports, select 'N/A':
Required

CLAIM INFORMATION
1. Full Name of Firm:
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2. Policy Number:
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3. Full Name of Individual(s):
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EMail Address:
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4. Full Name of Claimant:
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5. Indicate whether:
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6. Date of Alleged Error:
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7. Date of Claim:
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8. Additional Defendants:
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9. If Closed: Total Loss Paid Including Deductible $
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Indicate whether:
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10. If Pending: Claimant’s Settlement Demand $
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Defendant’s Offer for Settlement $
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Insurer’s Loss Reserve (may be obtained by requesting a loss run from Insurance Company) $
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Deductible $
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Is claim in suit?
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11. Description of claim (provide enough information to allow evaluation):
A. Alleged act, error or omission upon which Claimant bases claim:
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B. Description of case and event:
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C. Description of the type and extent of injury or damage allegedly sustained:
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12. Provide name of insurance company to which this claim was reported and the date reported:
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SUBMIT COMPLETED APPLICATION

The undersigned is authorized to sign this application on behalf of all persons in the Firm to be insured and declares to the best of his/her knowledge and belief that the information provided in this application, and attachments, is 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 a policy of insurance.

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 against the Firm or incidents that might result in a claim against the Firm or any attorney to the present insurance company before its policy expires. Failure to do so may result in a loss of coverage.


 

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.

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