• Lawyers Professional Liability Application

    NOTICE: THIS IS AN APPLICATION FOR A CLAIMS-MADE AND REPORTED POLICY, WHICH SUBJECT TO ITS PROVISIONS APPLIES ONLY TO CLAIMS WHICH ARE BOTH FIRST MADE AGAINST THE INSURED AND REPORTED TO THE INSURER DURING THE POLICY PERIOD OR ANY EXTENDED REPORTING PERIOD, IF APPLICABLE. CLAIM EXPENSES ARE INCLUDED WITHIN THE LIMIT OF LIABILITY. THE INFORMATION CONTAINED AND STATEMENTS MADE WITHIN THIS APPLICATION ARE INCORPORATED INTO, AND WILL FORM THE BASIS OF, ANY POLICY OF INSURANCE ISSUED BY THE INSURER. THE APPLICANT AND ALL SIGNORS OF THIS APPLICATION WARRANT THAT THE INFORMATION CONVEYED IS TRUE AND CORRECT. THE LIMIT OF LIABILITY AVAILABLE TO PAY SETTLEMENTS OR JUDGMENTS WILL BE REDUCED, AND MAY BE EXHAUSTED, BY CLAIM EXPENSES.

  • Please fully answer all questions and submit requested information. Boldfaced terms are defined in the Policy and have the same meaning in this Application. Any information provided, whether physically attached or available on the Applicant’s web site, shall be deemed incorporated into this Application.
  • A. General Information
  • *Minimum allowable limits for defense within limits is $1000,000/$1000,000 [Applicable in AR, OK, & SD]
  • Expenses in Addition to Limits:
  • If more than 10, attach additional sheets as necessary
  • Partner/Owner/Member (P), Employed Attorney (E), Of Counsel (OC), Independent Contractor (IC), Part-Time Attorney (PT)
  • 7. Please complete the following chart for your 5 (five) largest clients based either on your
    (check one).
  • 8. Does the Named Insured practice from Additional Locations?

  • If yes, please provide details on the last page of this Application, including the address of such locations, the name of the Partner in charge, the % of the Named Insured’s total gross revenues from such location, the # of attorneys and staff at each location, and how such offices are controlled.

  • B. Firm Practice Profile

    9. Indicate the percentages of overall billings generated by the following areas of practice:

  • Administrative
  • Foreign
  • Admiralty - Defense
  • Health Care
  • Admiralty - Plaintiff
  • Immigration/Naturalization
  • Anti-trust/Trade Regulation
  • Insurance Coverage
  • Appellate
  • Insurance Defense
  • Arbitration/Mediation
  • Investment Counseling/Money Management
  • Aviation
  • Labor Law - Management
  • Banking/Financial Institutions*(Fin. Institutions Supp)
  • Labor Law – Union
  • Bankruptcy
  • Labor Litigation - Defense
  • BI/PI Defendant General Liability
  • Labor Litigation - Plaintiff
  • BI/PI Defendant Medical Malpractice
  • Litigation – General – Defense
  • BI/PI Defendant Other
  • Litigation – General – Plaintiff* (Plaintiff Supplement)
  • BI/PI Defendant Products Liability
  • Mergers & Acquisitions
  • BI/PI Plaintiffs General Liability* (Plaintiff Supplement)
  • Municipal/Governmental - Other
  • BI/PI Plaintiffs Medical Malpractice* (Plaintiff Supplement)
  • Municipal/Governmental - Zoning
  • BI/PI Plaintiffs Other* (Plaintiff Supplement)
  • Oil/Gas/Minerals* (Oil/Gas/Minerals Supplement)
  • BI/PI Plaintiffs Product Liability* (Plaintiff Supplement)
  • Patent* (Intellectual Property Supplement)
  • Civil Rights/Discrimination
  • Probate/Wills/Estates* - Assets <1M (Probate/Wills/Estates Supplement)
  • Class Action/Mass Tort-Defense* (Class Action Supplement)
  • Probate/Wills/Estates* - Assets 1M-5M (Probate/Wills/Estates Supplement)
  • Class Action/Mass Tort-Plaintiff* (Class Action Supplement)
  • Probate/Wills/Estates* – Assets >5M (Probate/Wills/Estates Supplement)
  • Collection/Repossession* (Collections Supplement)
  • Public Utilities
  • Commercial Law
  • Real Estate – Commercial* (Real Estate Supplement)
  • Communication/FCC
  • Real Estate – Escrow Agent* (Real Estate Supplement)
  • Construction/Building Contracts
  • Real Estate – Foreclosure* (Real Estate Supplement)
  • Consumer Claims
  • Real Estate – Residential* (Real Estate Supplement)
  • Copyright/Trademark* (Intellectual Property Supplement)
  • Real Estate – Synd./Development* (Real Estate Supplement)
  • Corporate-General
  • Real Estate – Title Work* (Real Estate Supplement)
  • Corporate Formation
  • School Law
  • Criminal
  • Securities/Bonds/Loans* (Securities Supplement)
  • Domestic Relations
  • Social Security Law
  • Eminent Domain
  • Taxation – Corporate – Opinions
  • Employee Benefits/ERISA
  • Taxation – Corporate – Preparation
  • Entertainment/Sports* (Entertainment Supplement)
  • Taxation – Individual
  • Environmental* (Environmental Supplement)
  • Water Rights Law
  • Environmental Lit-Defense
  • Workers Comp - Defense
  • Environmental Lit-Plaintiff* (Plaintiff Supplement)
  • Workers Comp - Plaintiff
  • Workers Comp - Plaintiff
  • Environmental Lit-Plaintiff* (Plaintiff Supplement)
  • C. Firm Insurance History
  • 10. For the past five years, state:

  • 11. Has the Named Insured or any Predecessor Firm ever had a gap in coverage?
    If yes, please provide a detailed narrative below

  • 12. a. Is coverage desired for any Predecessor Firm? If yes, please complete the Predecessor Firm chart on the last page of this Application

  • 13.a.Any exclusions on the current policy that were specifically tailored for the Named Insured?

  • b. Has the Named Insured or Predecessor Firm purchased any extended reporting (tail) coverage?

  • c. Has any attorney in the Named Insured obtained any extended reporting (tail) coverage during the last seven years?

  • If yes, explain the details for each such attorney, identifying the carrier and the effective dates of such coverage on the last page of this Application.
  • D. Internal Procedures
  • 14. Conflicts of Interest

  • a. Do you have procedures in place for identifying conflicts of interest?

  • b. Are conflict checks performed before accepting any new cases/matters?

  • c. If a potential or actual conflict exists, is written disclosure made to all parties involved?

  • e. How often is the conflict of interest system updated?
  • 15. Docket Control

  • b. How frequently are deadlines cross-checked?

  • c. Are at least two individuals involved in maintaining the docket control system?
  • 16. Engagement Letters

    Indicate percentage of use. If not used by the Named Insured, indicate 0%. All blanks should be answered

  • - Do they clearly define who is being represented?

  • - Do they define the specific services to be performed?

  • - Do they describe billing rate and procedures?

  • 17. If you are a sole proprietor, have you made arrangements with another attorney to handle your cases/matters when you are on an extended absence from your practice?

  • 18. Does the Named Insured share office space, letterhead or support staff with another firm? If yes, please provide details on the last page of this Application.
  • E. Firm Clients, Billing and Collection
  • If more than 2 times

  • b. Have steps been taken to avoid a possible counter suit?

  • c. Have steps been taken to prevent fee suits in the future?
  • F. Attorney Profiles
  • NOTE: Answer the following questions only after making a reasonable and thorough inquiry of all attorneys in the Firm:
  • 22. In the past five years, has any current or former attorney of the Named Insured:

  • a. Been refused admission to practice, or the subject of a bar complaint or disciplinary action?

  • b. Been declined, cancelled or non-renewed for professional liability insurance coverage? (NOT APPLICABLE IN MISSOURI)

  • c. Provided professional services other than legal services?

  • d. Suffered from an impairment that might hinder their ability to provide competent, courteous and timely Professional Services? If yes to any of the above, provide an explanation for each such attorney at the end of this Application.

  • 23. In the past five years, has any current or former attorney of the Named Insured:

  • a. Handled any class action or mass tort litigation on behalf of the Named Insured or other firm?

  • b. Provided Professional Services in any way related to a security or securities transactions?

  • c. Provided Professional Services to, or served as a fiduciary, committee member, director, officer, partner or employee, of any Financial Institution?

  • If yes to any of the above, complete the Class Action, Securities, and/or Financial Institutions Supplements, as applicable.

  • 24. Does any attorney in the Named Insured (including any such attorney’s spouse):

  • a. Serve as an officer, director, partner, committee-member or employee of any outside entity?

  • b. Hold any ownership or equity interest in any clients of the Named Insured?

  • If yes to any of the above, complete the Outside Interests chart on the last page of this Application

  • G. Claims Experience

  • 25. After inquiry, has the Named Insured or any attorneys to be insured under this policy:

  • a. Been the subject of a professional liability claim or suit, or entered a tolling agreement with a client with respect to a threatened professional liability claim, in the last five (5) years (or earlier if the claim is still open)?

  • b. Have knowledge or information of any fact, circumstance or actual or alleged act, error or omission which may reasonably be expected to give rise to a professional liability claim(s) under the proposed policy?

  • If yes to any of the above, complete the Claim Supplement.

  • It is understood and agreed that, without limiting any rights of the underwriter, if such knowledge or information exists, any claim arising therefrom is excluded from this proposed insurance.

  • H. Warranty

    The undersigned authorized owner, partner, director, or officer represents and warrants on behalf of the Named Insured and all persons/entities for whom insurance is being sought that to the best of his/her knowledge and belief after diligent inquiry, the statements set forth herein and attached hereto are true. It is understood that the statements in this Application, including material submitted to or obtained by the underwriter, are material to the acceptance of the risk, and relied upon by the underwriter. The Insureds further agree that in the event of any material misrepresentation or omission in the Application, including materials submitted to or obtained by the underwriter, this Policy shall be void. The undersigned authorized owner, partner, director or officer of the applicant declares that the statements set forth herein are true. The undersigned agrees that if the information supplied on this Application changes between the date of this Application and the effective date of the insurance, that he/she will immediately notify the Insurer of such changes, and the Insurer may withdraw or modify any outstanding quotations or authorizations or agreements to bind the insurance

  • Signing this Application does not bind the applicant or the Insurer to complete the insurance, but it is agreed that this Application shall be the basis of the contract should a policy be issued, and it will be attached to and become part of the Policy.
  • SIGNED * :

  • Applicable in FL, IA and NH: In addition to the signature above, please complete the following:
  • Producer Signature

  • Fraud Prevention – General Warning

    NOTICE: Any person who knowingly, or knowingly assist another, files an application for insurance or claim containing any false, incomplete or misleading information for the purpose of defrauding or attempting to defraud an Insurance Company may be guilty of a crime and may be subject to criminal and civil penalties and loss of insurance benefits

  • Attention: Insureds in AL

    Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines, or confinement in prison, or any combination thereof.

    Attention: Insureds in CO
    It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable for insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

    Attention: Insureds in DC
    WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

    Attention: Insureds in FL
    Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree

    Attention: Insureds in KS
    A person who commits a fraudulent insurance act is guilty of a crime and may be subject to restitution, fines and confinement in prison. A fraudulent insurance act means an act committed by any person who, knowingly and with the intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral or telephonic communication or statement as part of, or in support of, an application for insurance, or the rating of an insurance policy, or a claim for payment or other benefit under an insurance policy, which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto.

    Attention: Insureds in KY
    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.

    Attention: Insureds in LA
    Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

    Attention: Insureds in MD
    Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

    Attention: Insureds in ME
    It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or denial of insurance benefits.

    NOTICE: Insureds in MN
    A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

    Attention: Insureds in NJ
    Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties

    Attention: Insureds in NM
    Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.

    Attention: Insureds in OH
    Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

    Attention: Insureds in OK
    WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

    Attention: Insureds in OR
    Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents materially false information in an application for insurance may be guilty of a crime and may be subject to fines and confinement in prison. In order for us to deny a claim on the basis of misstatements, misrepresentations, omissions or concealments on your part, we must show that:

    A. The misinformation is material to the content of the policy;
    B. We relied upon the misinformation; and
    C. The information was either:

    1. 1)Material to the risk assumed by us; or
    2. 2)Provided fraudulently.
    For remedies other than the denial of a claim, misstatements, misrepresentations, omissions or concealments on your part must either be fraudulent or material to our interests.
    With regard to fire insurance, in order to trigger the right to remedy, material misrepresentations must be willful or intentional. Misstatements, misrepresentations, omissions or concealments on your part are not fraudulent unless they are made with the intent to knowingly defraud.

    Attention: Insureds in PA
    Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim 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 and subjects such person to criminal and civil penalties.

    Attention: Insureds in RI
    Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

    Attention: Insureds in TN, VA, and WA
    It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.

    Attention: Insureds in VT
    Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.

  • Attention: Insureds in AL

    Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines, or confinement in prison, or any combination thereof.

    Attention: Insureds in CO
    It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable for insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

    Attention: Insureds in DC
    WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

    Attention: Insureds in FL
    Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree

    Attention: Insureds in KS
    A person who commits a fraudulent insurance act is guilty of a crime and may be subject to restitution, fines and confinement in prison. A fraudulent insurance act means an act committed by any person who, knowingly and with the intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral or telephonic communication or statement as part of, or in support of, an application for insurance, or the rating of an insurance policy, or a claim for payment or other benefit under an insurance policy, which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto.

    Attention: Insureds in KY
    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.

    Attention: Insureds in LA
    Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

    Attention: Insureds in MD
    Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

    Attention: Insureds in ME
    It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or denial of insurance benefits.

    NOTICE: Insureds in MN
    A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

    Attention: Insureds in NJ
    Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties

    Attention: Insureds in NM
    Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.

    Attention: Insureds in OH
    Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

    Attention: Insureds in OK
    WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

    Attention: Insureds in OR
    Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents materially false information in an application for insurance may be guilty of a crime and may be subject to fines and confinement in prison. In order for us to deny a claim on the basis of misstatements, misrepresentations, omissions or concealments on your part, we must show that:

    A. The misinformation is material to the content of the policy;
    B. We relied upon the misinformation; and
    C. The information was either:

    1. 1)Material to the risk assumed by us; or
    2. 2)Provided fraudulently.
    For remedies other than the denial of a claim, misstatements, misrepresentations, omissions or concealments on your part must either be fraudulent or material to our interests.
    With regard to fire insurance, in order to trigger the right to remedy, material misrepresentations must be willful or intentional. Misstatements, misrepresentations, omissions or concealments on your part are not fraudulent unless they are made with the intent to knowingly defraud.

    Attention: Insureds in PA
    Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim 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 and subjects such person to criminal and civil penalties.

    Attention: Insureds in RI
    Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

    Attention: Insureds in TN, VA, and WA
    It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.

    Attention: Insureds in VT
    Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.

  • Attention: Insureds in AL

    Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines, or confinement in prison, or any combination thereof.

    Attention: Insureds in CO
    It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable for insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

    Attention: Insureds in DC
    WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

    Attention: Insureds in FL
    Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree

    Attention: Insureds in KS
    A person who commits a fraudulent insurance act is guilty of a crime and may be subject to restitution, fines and confinement in prison. A fraudulent insurance act means an act committed by any person who, knowingly and with the intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral or telephonic communication or statement as part of, or in support of, an application for insurance, or the rating of an insurance policy, or a claim for payment or other benefit under an insurance policy, which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto.

    Attention: Insureds in KY
    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.

    Attention: Insureds in LA
    Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

    Attention: Insureds in MD
    Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

    Attention: Insureds in ME
    It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or denial of insurance benefits.

    NOTICE: Insureds in MN
    A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

    Attention: Insureds in NJ
    Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties

    Attention: Insureds in NM
    Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.

    Attention: Insureds in OH
    Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

    Attention: Insureds in OK
    WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

    Attention: Insureds in OR
    Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents materially false information in an application for insurance may be guilty of a crime and may be subject to fines and confinement in prison. In order for us to deny a claim on the basis of misstatements, misrepresentations, omissions or concealments on your part, we must show that:

    A. The misinformation is material to the content of the policy;
    B. We relied upon the misinformation; and
    C. The information was either:

    1. 1)Material to the risk assumed by us; or
    2. 2)Provided fraudulently.
    For remedies other than the denial of a claim, misstatements, misrepresentations, omissions or concealments on your part must either be fraudulent or material to our interests.
    With regard to fire insurance, in order to trigger the right to remedy, material misrepresentations must be willful or intentional. Misstatements, misrepresentations, omissions or concealments on your part are not fraudulent unless they are made with the intent to knowingly defraud.

    Attention: Insureds in PA
    Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim 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 and subjects such person to criminal and civil penalties.

    Attention: Insureds in RI
    Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

    Attention: Insureds in TN, VA, and WA
    It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.

    Attention: Insureds in VT
    Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.

  • Application Addendum

    Applicable in AK, FL, KS, KY, ME, MT, NC, OK, OR, SD, WV: As may be used within this application, the word “warrant”/”Warranty” is replaced with the word “represents”/“representation”.

    Applicable in Florida: The following statement is added and supersedes any conflicting statement in the application:

    H. Representation
    The undersigned authorized owner, partner, director, or officer represents on behalf of the Named Insured and all persons/entities for whom insurance is being sought that to the best of his/her knowledge and belief after diligent inquiry, the statements set forth herein and attached hereto are true. It is understood that the statements in this Application, including material submitted to or obtained by the underwriter, are material to the acceptance of the risk, and relied upon by the underwriter. The Insureds further agree that in the event of any material misrepresentation or omission in the Application, including materials submitted to or obtained by the underwriter, this Policy may be void pursuant to Section 627.409, Florida Statutes. The undersigned authorized owner, partner, director or officer of the applicant declares that the statements set forth herein are true. The undersigned agrees that if the information supplied on this Application changes between the date of this Application and the effective date of the insurance, that he/she will immediately notify the Insurer of such changes, and the Insurer may withdraw or modify any outstanding quotations or authorizations or agreements to bind the insurance.

    Applicable in Georgia: As may be used within this application, the word “warrant” is replaced with the word “certify”. The following statement is added and supersedes any conflicting statement in the application:

    H. Warranty
    The undersigned authorized owner, partner, director, or officer represents and warrants on behalf of the Named Insured and all persons/entities for whom insurance is being sought that to the best of his/her knowledge and belief after diligent inquiry, the statements set forth herein and attached hereto are true. It is understood that the statements in this Application, including material submitted to or obtained by the underwriter, are material to the acceptance of the risk, and relied upon by the underwriter. The Insureds further agree that in the event of any material misrepresentation or omission in the Application, including materials submitted to or obtained by the underwriter, coverage may be denied and this Policy may be canceled. The undersigned authorized owner, partner, director or officer of the applicant declares that the statements set forth herein are true. The undersigned agrees that if the information supplied on this Application changes between the date of this Application and the effective date of the insurance, that he/she will immediately notify the Insurer of such changes, and the Insurer may withdraw or modify any outstanding quotations or authorizations or agreements to bindthe insurance.

    Applicable in Kansas and South Dakota: The following statement is added and supersedes any conflicting statement in the application:

    H. Warranty
    The undersigned authorized owner, partner, director, or officer represents on behalf of the Named Insured and all persons/entities for whom insurance is being sought that to the best of his/her knowledge and belief after diligent inquiry, the statements set forth herein and attached hereto are true. It is understood that the statements in this Application, including material submitted to or obtained by the underwriter, are material to the acceptance of the risk, and relied upon by the underwriter. The Insureds further agree that in the event of any material misrepresentation or omission in the Application, including materials submitted to or obtained by the underwriter, this Policy shall be canceled. The undersigned authorized owner, partner, director or officer of the applicant declares that the statements set forth herein are true. The undersigned agrees that if the information supplied on this Application changes between the date of this Application and the effective date of the insurance, that he/she will immediately notify the Insurer of such changes, and the Insurer may withdraw or modify any outstanding quotations or authorizations or agreements to bind the insurance.

    Applicable in Louisiana and Washington: The following statement is added and supersedes any conflicting statement in the application:

    H. Warranty
    The undersigned authorized owner, partner, director, or officer represents and warrants on behalf of the Named Insured and all persons/entities for whom insurance is being sought that to the best of his/her knowledge and belief after diligent inquiry, the statements set forth herein and attached hereto are true. It is understood that the statements in this Application, including material submitted to or obtained by the underwriter, are material to the acceptance of the risk, and relied upon by the underwriter. The Insureds further agree that in the event of any material misrepresentation or omission made by the Insured with the intent to deceive in the Application, including materials submitted to or obtained by the underwriter, this Policy shall be void. The undersigned authorized owner, partner, director or officer of the applicant declares that the statements set forth herein are true. The undersigned agrees that if the information supplied on this Application changes between the date of this Application and the effective date of the insurance, that he/she will immediately notify the Insurer of such changes, and the Insurer may withdraw or modify any outstanding quotations or authorizations or agreements to bind the insurance.

    Applicable in Maine: The following statement is added and supersedes any conflicting statement in the application:

    H. Warranty
    The undersigned authorized owner, partner, director, or officer represents and warrants on behalf of the Named Insured and all persons/entities for whom insurance is being sought that to the best of his/her knowledge and belief after diligent inquiry, the statements set forth herein and attached hereto are true. It is understood that the statements in this Application, including material submitted to or obtained by the underwriter, are material to the acceptance of the risk, and relied upon by the underwriter. The Insureds further agree that in the event of any material misrepresentation or omission in the Application, including materials submitted to or obtained by the underwriter, this Policy may be canceled. The undersigned authorized owner, partner, director or officer of the applicant declares that the statements set forth herein are true. The undersigned agrees LG-LPL-000001-ME (09-21) © , 2021 Page 8 of 8 that if the information supplied on this Application changes between the date of this Application and the effective date of the insurance, that he/she will immediately notify the Insurer of such changes, and the Insurer may withdraw or modify any outstanding quotations.

    Applicable in NJ: The provision stating “CLAIM EXPENSES ARE INCLUDED WITHIN THE LIMIT OF LIABILITY” in the Notice at the top of this application is replaced with the words “CLAIM EXPENSES MAY BE INCLUDED WITHIN THE LIMIT OF LIABILITY”.

  • Predecessor Firms (please attach additional sheets as necessary)

  • Outside Interests (please attach additional sheets as necessary)

  • Supplemental Information

    Instructions:Use this form to provide additional information or request descriptions or explanations necessary to provide a true and complete response to all questions, statements or requests for information contained in the Application. Please identify the number of each question or statement on the Application to which your responses relate. If necessary, make additional copies of this form. Attach additional sheets if necessary. Please sign all forms in the Application.
  • SIGNED * :
  • This field is for validation purposes and should be left unchanged.

Real Estate Supplement

  • 9. In the past 12 months, what is the average annual number of real estate transactions other than purchase or sale handled by the Applicant Firm in each category below?

  • Party Performing Search

  • Residential Searches

  • Commercial Searches

  • APPLICANT UNDERSTANDS THE INFORMATION SUBMITTED HEREIN BECOMES A PART OF THE APPLICANT’S LAWYERS PROFESSIONAL
    LIABILITY INSURANCE APPLICATION AND IS SUBJECT TO THE SAME REPRESENTATIONS AND CONDITIONS.
  • Sign and date in ink
  • Signature:

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