Step 1: Application for Lawyers Professional Liability Insurance

Present policy expiration date
(or effective date desired, if no prior coverage):
 
Limits and deductibles requested. Not all deductibles are available with some limits options.
 
Deductible Options:
Per Claim
Aggregate
Per Claim with Policy Aggregate
If a larger deductible is desired specify:
 
1. Name of Your Firm:
  Individual
Partnership
Professional Service Corporation
Other
 
2. Address:
City:
State:    Zip:
County:
Within City Limits? Yes    No
 
3. Telephone Number:
Fax:
 
4. Year Firm Established:
 
5. Branch Office Address, if applicable:
 
6. Total Number of Lawyers in Firm:
Total Number of Non-Lawyer Employees:
 
7. Name All Lawyers. Indicate position in firm (Sole Practitioner, Partners, Shareholders, Associates or “Of Counsel”):

     Name Position Mo./Yr.
Admitted 		Years in
Practice
A.
B.
C.
D.
E.

 
8. Indicate the percentage of time (in total working hours) for each of the following areas of practice:

Practice Area %
A. Admiralty:
B. Anti Trust/Trade Regulations:
C. Banking:
D. Bankruptcy:
E. BI/PI Defendants:
F. BI/PI Plaintiffs:
G. Collection/Repossession:
H. Communications:
I. Copyright/Patent/Trademark:
J. Corporation Formation/Alteration
(Excluding Public Offerings):
K. Oil and Gas:
L. Public Utilities:
M. Real Estate:
N. Federal SEC:
O. Criminal:
P. Domestic Relations:
P. Entertainment:
R. Syndication:
S. Estate Planning:
T. Estate Probate/Trust:
U. International Law:
V. Foreign Practice:
W. Labor Relations:
X. Money Management:
Y. Municipal Law:
Z. State Securities (Including Public Offerings):
AA. Taxation:
BB. Workers Compensation/Defendants:
CC. Workers Compensation/Plaintiffs:
DD. Litigation (Non-Criminal):
EE. Litigation (General Civil):
FF. Environmental Law:
GG. Other:

Please Describe:

 
9. Indicate the firm’s annual gross billing category for the fiscal year preceding this application’s date:
 
10. Do 10% or more of your working hours come from one client account or a group of related client accounts? Yes    No
If yes, provide a narrative description of the type of services provided and your relationship:
 
Firm History
11. List the names of all firms of which the assets and liabilities of the former firm have been acquired by your firm.

Please put the Name of Firm, Year Established, and Number of Lawyers, one firm per line:
 
12. Has the name of your firm changed within the past five years? Yes    No
If yes, list the name(s) of firms used:
 
13. How many lawyers listed in Question 7 have received CLE Credit for twenty hours or more in the preceding KBA year? (July 1-June 30)
List those attorneys here:
 
Management of the Firm
14. 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.):
 
15. Does your firm share its office or expenses with any other attorney, law firm or organization? Yes    No
If yes, please answer the following questions:
A. Does your firm and any such person or organization share the same letterhead? Yes    No
B. Is there a work-for-space arrangement? Yes    No
C. If the other organization is a firm of lawyers, are there any case sharing arrangements? Yes    No
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.
 
16. Does the firm maintain a conflict of interest screening system? Yes    No
If yes, what methods are employed? Memory
Index File
Computer
Conflict Committee
New Client Review Meeting
 
17. Is any firm member serving as a director, officer, trustee, partner or employee of any client? Yes    No
If Yes, name the attorney, the client and the position served:
 
18. Does any attorney have any fiduciary responsibility to or possess any ownership interest in any client? Yes    No
If yes, name the client:
 
19. Describe any procedures in place to ensure that a lawyer is not overloaded with work:
 
20. Does the firm use a formal or informal new client screening procedure to review fees, case merit or client attitudes prior to case acceptance? Yes    No
Does the procedure include formal engagement, nonengagement and disengagement letters? Yes    No
 
21. Has any lawyer listed in Question 7 ever entered into any contract or agreement, oral or written, guaranteeing the result of any professional service rendered by him/her or by any person under his/her supervision? Yes    No
If yes, provide name and explain circumstances:
 
22. Has any lawyer listed in Question 7 ever been treated for alcohol or substance abuse? Yes    No
If yes, provide the name(s) of individuals:
 
23. Has any lawyer been convicted or pleaded guilty or no contest to a criminal offense involving moral turpitude or which constitutes a felony? Yes    No
If yes, provide name and explain circumstances:
 
Record Control
24. Does your firm use a formal system for record retention and control? Yes    No
Does the system used identify how long records should be maintained? Yes    No
Does the file system used separate inactive files from active files? Yes    No
Are inactive files closed and archived on a regular schedule? Yes    No
Are archived files destroyed after a certain number of years? Yes    No
Number of years:
 
25. Please indicate whether your firm is engaged in any of the following activities by checking “yes” or “no”. If yes, please indicate the percent of total working hours devoted to each activity and whether or not separate professional liability insurance is carried for this work.

Type of Activity Yes / No Total Working Hours Devoted to each Professional Insurance Carrier Expiration Mo/Day/Year
A. Insurance Agent Yes    No
B. Accountant Yes    No
C. Real Estate Broker Yes    No
D. Title Abstractor Yes    No
E. Title Agent Yes    No

 
26. Is any lawyer listed in Question 7 a public official? If so, please name attorney and describe the position:
 
27. List the lawyers involved in the incidental practice of law (independent of the firm’s law practice) for or on behalf of any organization, social agency or teaching institution and average number of hours per week devoted to such activities, with or without compensation.

Name of Lawyer Name of Organization Average # of Hours Per Week
A.
B.
C.

 
28. If any lawyer listed in Question 7 works 30 hours or less, a credit may be available. Please provide the name of the lawyer and the average number of hours per week devoted to law practice.

Name of Lawyer Weekly Hours Reason for Part-time
A.
B.
C.

 
29. Has any lawyer listed in Question 7 or any firm listed in Question 11 had any insurance company cancel, decline or refuse to renew professional liability insurance? Yes    No
If yes, please explain circumstances:
 
Claims
30. Within the past six years, has any professional liability claim been asserted or action filed or claim paid against the applicant or attorney listed in Question 7? Yes    No
If yes, complete supplemental claim form for each such claim or action.
 
31. Has any lawyer listed in Question 7 ever been reprimanded, censured, disciplined by or refused admission to practice, disbarred or suspended (including voluntary suspension) from practice by any bar association, court, administrative or regulatory agency? Yes    No
If yes, please explain circumstances:
 
32. Does any lawyer listed in Question 7 know of any present or prior incident, error, act or omission which could result in a professional liability claim against the applicant or any lawyer listed in Question 7 or firm listed in Question 11? Yes    No
If yes, please complete supplemental claim form and attach a copy of the notice that was sent to the insurance carrier involved.
 
Previous Insurance
33. List lawyers professional liability insurance carried for each of the past seven years (including firms listed in Question 11.) If none, state “none.” Coverage Basis:

Insurer Name Policy Number Limits of Liability Deductible (If Any) Policy Period Policy Claims Made / Period Occurrence
A.
B.
C.
D.
E.
F.
G.

 
The undersigned is authorized to sign this application on behalf of all persons to be insured and declares to the best of the knowledge and belief of all persons to be insured, 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 the Lawyers Mutual Insurance Company of Kentucky. Signing this application does not bind the applicant or Lawyers Mutual Insurance Company of Kentucky to issue a policy of insurance.

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.
 
Additional Information (Note Question # and Give Information):
 
Name of Firm:
 
Submitted By:
Applicant Name:

Title:

 
Important Reminder

Report any claims against you or incidents that might result in a claim against you to your present insurance company before its policy expires. Failure to do so may result in a loss of coverage.

See Supplemental Sheets NBOO3/8-96
 
 

 

Lawyers Mutual Insurance
Waterfront Plaza
323 West Main Street,
Suite 600
Louisville, KY 40202
Waterfront Plaza
KY Wats 1-800-800-6101
Ph. 502-568-6100
Fax 502-568-6103

Disclaimer:
The contents of this website 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 website to establish an attorney’s standard of due care for a particular situation. Rather, it is our intent to advise our insureds 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.