insurance for business

223 West Ohio Street  Chicago, IL 60654-4445  800-473-4722  312-379-2000  Fax: 312-379-2001  isbamutual.com LAWYERS PROFESSIONAL LIABILITY INSURANCE NEW BUSINESS APPLICATION (Application must be completed in ink or typewritten) NOTE: This coverage is provided on a “claims-made-and-reported” basis. Only claims which are first made against you and reported to us during the policy term are covered, subject to policy provisions. 1. Applicant Name: Contact Person: Phone Number: Fax Number: e-mail address: ( ( ) ) 2. Suite Number / Post Office Box: Street Address: City, County, State, Zip: / / / / / 3. 4. Current Policy Expiration Date/Desired Effective Date: Does Applicant practice from any other location? Yes No If yes, on Applicant letterhead please list the secondary locations, number of lawyers who practice from these locations and percentage of applicant’s billings derived from each location. 5. 6. Date Applicant Established: / / List all predecessor firms of Applicant over the past 10 years. (Predecessor firm means either (1) any law firm or professional legal corporation engaged in the practice of law that has undergone dissolution, of which 50% or more of the owners, officers or partners have affiliated with Applicant, and of which Applicant assumes at least 50% of the financial assets and liabilities; OR (2) any sole practitioner lawyer who has affiliated with Applicant, whose financial assets and liabilities have been assumed by Applicant.) Date of Merger/ Dissolution Number of Owners, Officers, or Partners Number of Employed Lawyers Percentage of Assumed Assets and Liabilities Name of Firm Date Formed 7. Indicate the total number of lawyers in your firm for whom coverage is desired, including independent contractors and of counsel lawyers: Each lawyer must be listed on our LAWYERS SUPPLEMENTAL APPLICATION. If you are a sole practitioner, YOUR information must be listed. 8. 9. 10. If you are a sole practitioner, how many hours per week do you devote to the private practice of law? Indicate the total number of non-lawyer employees in your firm: a. Indicate the total gross revenue (including any contingent fees) for: (1) Last fiscal year: $_____________ (2) Projection for current year: $_____________ All revenue information will be kept strictly confidential. IL NBApp 07/02 (rev. 04/11/2006) WEB 1 10. 1 2 3 4 5 6 7 8a 8b 9 10 11 12 13 14 15 16a 16b 16c 17 18 19a 19b 19c b. Indicate the percentage (%) of time Applicant’s practice is devoted to any of the following categories. (Pick the most specific category that applies.) TOTAL PERCENTAGE MUST EQUAL 100%. Administrative Admiralty Antitrust Appellate Arbitration/Mediation Banking/Savings & Loan Bankruptcy Bodily Injury/Personal Injury Defense Plaintiff Bonds * Civil Litigation ** Civil Rights/Discrimination Class Actions Collections Commercial Construction Corporate Acquisitions/Mergers * Formations General Criminal Elder Employment Employees Labor Management Labor Unions 20 21 22 23 24 25a 25b 25c 25d 25e 26 27 28 29 30 31 32 33 34a 34b 34c 35 36 37 Entertainment/Sports * Environmental * ERISA Estate Planning Estate/Probate/Trust/Wills Family Adoptions Divorce Domestic Relations High Profile Divorce Juvenile Fiduciary * Foreclosures Foreign General Litigation ** Governmental Guardianship Immigration Insurance Defense Intellectual Property Copyright * Patent * Trademark * International Investment Advice/Money Mgmt Lobbying 38a 38b 39 40 41 42a 42b 42c 42d 42e 43a 43b 43c 43d 43e 43f 44a 44b 45 46 47a 47b Medical Malpractice Defense Plaintiff Municipal Oil/Gas/Mining Other (must explain) ** Real Estate Commercial Developmt/Syndication * General Residential Title Securities Exempt Federal Limited Partnerships Private Placements Registered State Tax Opinion/Advice Preparations Traffic Utilities Workers Comp. Defense Plaintiff Should bechanges greater than 25% in the percentages shown in Question 10 b for 100 c. Do you foresee any the current year? If yes, please explain on Applicant letterhead. 11. During the past 5 years, has any member or former member of Applicant provided legal services in connection with: a. A financial institution in which he/she either (1) serves/served as a director, officer or committee member and/or (2) held equity interest? If yes, please complete our FINANCIAL INSTITUTION SUPPLEMENT. b. The issuance, offering or sale of securities? * Applicant must complete our supplement. 0 ** Applicant must provide a written description. Yes No Yes No Yes If yes, please complete our SECURITIES SUPPLEMENT. c. The formation, syndication, promotion, or management of any limited partnership or private placement? If yes, please complete our LIMITED PARTNERSHIP/PRIVATE PLACEMENT SUPPLEMENT. 12. During the past 5 years, has any Applicant member: a. b. Acted in the capacity of or with the title “trustee” for a client? Had discretionary investment authority over client funds? Yes Yes Yes No No No No If yes to any of the above, please complete our FIDUCIARY ACTIVITIES SUPPLEMENT. 13. During the past 5 years, has any Applicant member: a. b. c. Served as a director, officer, partner or employee of a past or present client? Had an equity interest in a past or present client? Engaged in business ventures with a past or present client? Yes Yes Yes No No No If yes to any of the above, please complete our OUTSIDE INTEREST SUPPLEMENT. IL NBApp 07/02 (rev. 04/11/2006) WEB 2 14. How many hours per week do Applicant members devote to outside business pursuits? Please describe the outside business pursuits: hours per week. 15. Does Applicant or any Applicant member perform legal services as an in-house employee of any corporation or public entity? If yes, please provide the name of corporation/public entity: Yes No Please note: In most instances, coverage will not be provided for legal services performed as an in-house employee of any corporation or public entity. 16. Does any one client’s total billable hours represent 25% or more of Applicant’s total gross revenue? Yes No If yes, please provide on Applicant letterhead: client’s name, industry, nature of business, nature of legal services rendered, and percentage of Applicant’s gross revenue. 17. Does Applicant OWN a title agency that is separate from Applicant firm? a. b. Are these services provided solely to Applicant’s clients in connection with the provision of legal services? If yes, is coverage requested? Yes Yes Yes No No No If coverage is requested, please complete our SEPARATELY OWNED/OPERATED TITLE AGENCY OR COMPANY SUPPLEMENT. 18. During the past 5 years, has any insurance carrier cancelled, refused to renew, or declined to provide professional liability insurance to Applicant or any Applicant member? If yes, please provide explanation on Applicant letterhead. 19. List Applicant’s professional liability insurance carrier(s) FOR EACH OF THE PAST 5 YEARS as indicated below. If Applicant has not been in existence for 5 years, please provide the insurance history for each lawyer on Applicant letterhead. It is important that this information be completed because it directly affects the premium. Policy Period From MM/DD/YY To MM/DD/YY Insurance Company Limit of Liability per Claim/Aggregate Premium Amount Number of Lawyers Covered Yes No Deductible Firm Name 20. Does Applicant’s current policy contain a prior acts limitation or retroactive date for Applicant FIRM? a. If yes, please provide the date: / / Yes No Please provide individual lawyers’ prior acts exclusion dates on our LAWYERS SUPPLEMENTAL APPLICATION. b. Has Applicant or any current member of Applicant firm ever purchased an extended reporting period endorsement coverage (tail coverage)? If yes, what date did it go into effect? What is the length of the purchased extended reporting period endorsement coverage (tail)? If you do not know the answer to Question 19, please provide a copy of Applicant’s current policy, including the declarations page and all endorsements. 21. a. During the past 5 years has any claim been made against: Applicant or a predecessor firm; any current member of Applicant or a predecessor firm; or, to your knowledge, any former member of Applicant or a predecessor firm? Yes No Yes No IL NBApp 07/02 (rev. 04/11/2006) WEB 3 21. b. Is any current member of Applicant aware of any circumstance or incident that may result in a claim or suit? Yes No If yes to 21 a or b, please complete our SUPPLEMENTAL CLAIM INFORMATION form for each claim or incident. Please indicate the number of Supplemental Claim Information forms that are being submitted: ______. (IT IS UNDERSTOOD THAT ALL ITEMS UNDER 21 a AND b WILL BE EXCLUDED FROM THE PROPOSED INSURANCE. FURTHERMORE, APPLICANT ACKNOWLEDGES THAT THE INFORMATION SOUGHT IS MATERIAL TO THE COMPANY AND ANY INACCURACY, WHETHER OR NOT INTENTIONAL, MAY ALLOW THE POLICY TO BE VOIDED.) 22. Has Applicant sued clients for fees within the past 24 months? If yes, how many suits were filed? If yes, please complete our FEE SUIT SUPPLEMENT. 23. a. Has any Applicant member, past or present, ever been disbarred, suspended, refused admittance to practice, reprimanded, sanctioned, or held in contempt by any court, administrative agency, regulatory body, or the ARDC? Yes No Yes No If yes, please provide details on Applicant letterhead and include a copy of the order or final decision. b. Has any Applicant member, past or present, had a disciplinary complaint, grievance, request for an investigation of a lawyer, or inquiry made to any administrative agency, court, regulatory body, or the ARDC in the past 5 years? Yes No If yes, please provide details on Applicant letterhead and attach a copy of the complaint or grievance, your response, and the resolution. 24. a. Please check all planned docket and date control systems maintained in Applicant office: Single Calendar Computer b. c. Dual Calendar Firm Wide Calendar Tickler System Other Advise how often Applicant calendars are cross-checked. Please check all persons that enter or maintain Applicant docket and date control system(s): Lawyer Docket Department Paralegal/Law Clerk Office Manager Secretary Other 25. a. How does Applicant identify and maintain conflict of interest information? Single Index (card/files) Memo/e-mail to lawyers Multiple Indexes (card/files) Other Computerized System b. Does Applicant’s information system capture the following? (1) Client name (2) Opposing party (3) Opposing counsel Yes Yes Yes No No No (4) Client principals (5) Client subsidiaries (6) Other Yes Yes No No c. d. Are all conflict of interest situations involving Applicant and its clients disclosed in writing to the clients? Does Applicant’s information system capture: (1) (2) Lawyer/client relationship established by acquired, merged or predecessor firms? Data to allow Applicant to screen for potential conflicts of interest from lateral hires, both lawyer and non-lawyer staff? Yes No Yes Yes Yes No No No 26. Do you use written fee or retainer agreements and/or engagement letters when accepting work? If no, please explain how you eliminate misunderstandings about the scope and cost of services being provided. 27. Do you use written declination or non-engagement letters when declining work? If no, please explain how you eliminate misunderstandings about representation. 28. If you are a sole practitioner, do you arrange for a back-up lawyer in your absence? If yes, please identify the lawyer: Yes No Yes No IL NBApp 07/02 (rev. 04/11/2006) WEB 4 29. Does Applicant share office space with any other lawyers or other professionals? Yes No If yes, please explain on Applicant letterhead by identifying office sharers, whether or not Applicant associates on files, and if the office sharers carry professional liability insurance. If they are not separately insured, they will be specifically excluded. 30. Does Applicant case-share, utilize co-counsel or of-counsel, refer or delegate cases, or use independent contractors? Yes No If yes, please describe on Applicant letterhead the nature of legal services, percentage of Applicant’s gross revenue, name and location of each lawyer/firm, and if the lawyer/firm carries professional liability insurance. If they are not separately insured, they will be specifically excluded. 31. Does Applicant advertise for professional services? If yes, do you advertise via: Direct mail or circular Directories Periodicals Radio Other TV Yes No Website Please list web address: Please attach copies of all printed advertisements and/or transcripts of any TV or radio advertisements. 32. Furnish a copy of Applicant’s business letterhead, and the letterhead of any other lawyer or firm on which your name appears, including all different styles. Please explain any inconsistencies between the letterhead and information provided on the application. 33. In selecting a limit of liability and deductible, please remember that the limits apply per claim, and are shared by all members. DEDUCTIBLE EACH CLAIM $ 5,000 $10,000 $15,000 $25,000 Higher LIMIT OF LIABILITY EACH CLAIM / ANNUAL AGGREGATE $ 250,000 / $ 500,000 $2,000,000 / $2,000,000 $ 500,000 / $ 500,000 $2,000,000 / $4,000,000 $ 500,000 / $1,000,000 $3,000,000 / $3,000,000 $1,000,000 / $1,000,000 $4,000,000 / $4,000,000 $1,000,000 / $2,000,000 $5,000,000 / $5,000,000 Higher $ $1,000 $2,000 $2,500 $3,000 $4,000 $ I/We affirm that the information contained herein is true and complete to the best of my / our knowledge and that it shall be the basis of the policy of insurance and deemed incorporated therein should the Company evidence its acceptance of this application by issuance of a policy. Signature of Owner, Partner, or Officer Print Name Title Date Unless the application is fully completed, no quotes can be issued or coverage bound. Signing this form and tendering premium does not bind the Company to provide the insurance. IL NBApp 07/02 (rev. 04/11/2006) WEB 5 LAWYERS SUPPLEMENTAL APPLICATION Please complete the following for each lawyer in your firm for whom coverage is desired, including independent contractors and of counsel lawyers. Applicant Name: (O), (OF), (D), (OC), (P), (E), (IC) (1) Date Admitted to ILLINOIS Bar MM/DD/YY Date Private Practice Started MM/DD/YY (2) Lawyer’s Individual Prior Acts Exclusion Date MM/DD/YY ARDC Number Lawyer Name/ e-mail Address ISBA Member Number (3) Date Joined Applicant MM/DD/YY # of hours per year worked for Applicant 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. (1) (2) (3) Designation codes: (O) = Owner, (OF) = Officer, (D) = Director, (OC) = Of Counsel, (P) = Partner, (E) = Employee, (IC) = Independent Contractor If this date is different from the date the lawyer was admitted to the bar, please explain. Please include all numbers. Note: Coverage will not apply to an Independent Contractor or Of Counsel unless listed above, and may require an additional premium. CLEAR FORM IL NBApp 07/02 WEB 6 PRINT FORM