• Lawyers Mutual Insurance
  • Lawyers Mutual Insurance
  • Lawyers Mutual Insurance
Add an Attorney

ATTORNEY INFORMATION
*Last Name:
Required
*First Name:
Required
Gender:
Required
*Firm Name:
Required
*Policy Number:
Required
*Hiring Date:
Required
*Attorney's Email:
Required
*Date Admitted to the Kentucky Bar Association:
Required
*KBA Number:
Required
*Do you wish to pick up the new attorney prior acts?
Required
If yes, please provide insurance history:
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*Have you ever been insured in the past?:
Required
If yes, please provide prior insurance:
Required
Additional State Licensed, if any (year, bar number):
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Previous Insurance Carrier Name: Previous Insurance Carrier Start Date: Previous Insurance Carrier Stop Date:
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GENERAL INFORMATION
Previous Employer/Firm:
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*Has the applicant ever been reprimanded by or refused admission to practice, disbarred or suspended from practice before any court or administrative agency, subject of a grievance or any complaint filed with the Kentucky Bar Association or any other Bar organization?:
Required
If the answer is yes, submit full details:
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*Have any claims or suits been made against the applicant?:
Required
If the answer is yes, submit full details:
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*Does the applicant know of any circumstance, act, error or omission that could form the basis for the assertion of a claim?:
Required
If the answer is yes, submit full details:
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*Has any insurance for any applicant been declined, cancelled, specially rated, had the deductible increased, policy limits decreased or subject to a special endorsement restricting coverage?:
Required
If the answer is yes, submit full details:
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*Are you a salaried employee of any entity other than the applicant firm?:
Required
If yes, please list employer and describe the nature of employment, as well as percentage of total time devoted to this activity:
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*Are you a partner, associate or employee of another law firm other than the applicant firm?:
Required
If yes, please name firm:
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*Will the applicant be involved in securities regulatory practice?:
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If the answer is yes, submit full details:
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*Has the applicant ever been convicted of a criminal offense other than traffic offenses?:
Required
If yes, state the nature of the offense, the charge and the outcome:
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*Is the applicant abusing drugs, alcohol or any chemical substance, or suffering from emotional distress?:
Required
If yes, submit full details:
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*Person Completing Application:
Required
*Date of Application:
Required
Paperwork:
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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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