THE POLICY YOU ARE APPLYING FOR IS A CLAIMS-MADE AND REPORTED POLICY, AND SUBJECT TO ITS PROVISIONS, APPLIES ONLY TO ANY CLAIM BOTH FIRST MADE AGAINST AN INSURED AND REPORTED IN WRITING TO THE COMPANY DURING THE POLICY PERIOD, NO COVERAGE EXISTS FOR CLAIMS FIRST MADE AFTER THE END OF THE POLICY PERIOD UNLESS, AND TO THE EXTENT, THE EXTENDED REPORTING PERIOD APPLIES. DEFENSE COSTS, AS WELL AS ANY LOSSES REDUCE THE LIMIT OF LIABILITY AND ARE SUBJECT TO THE RETENTION. PLEASE REVIEW THE POLICY CAREFULLY AND DISCUSS COVERAGE WITH YOUR INSURANCE AGENT OR BROKER.

1. The precise registered name of the applicant firm to be insured, as reflected on the firm’s letterhead:

17. Total number of attorneys: List all of the firm’s attorneys. Differences between the date attorney began practicing law for other than a corporate or governmental entity and the date the attorney was admitted to the Bar must be explained on a separate sheet of paper following the same format. List additional attorneys on a separate sheet in the same format.

A Associate	SPC Special Counsel	OC Of Counsel
MEM Member of Firm	D Director	SHH Shareholder
SP Solo Practitioner	O Owner	IC Independent Contractor
CC Co-counsel	STC Staff Counsel	OF Officer
MGR Manager	E Employee	STH Stockholder

Partner Designations:

EP Equity Partner

NP Non-equity Partner

P Partner

LLP Limited Liability Partner

RP Retired Partner

* does not include courses taken on the West Legal Ed website.

18. Guidelines for completing this section:

a. Express percentages of time devoted (billable hours) in each area during the previous year.
b. Indicate percentages in whole numbers next to the type of law you practice, not the business client you represent.
c. Be as accurate as possible, as casual estimates may cause inappropriate evaluation of your practice.
d. All litigation should be coded as “civil litigation” with the exception of “criminal”, “personal injury-plaintiff” and “intellectual property” which should be coded to their respective Area of Practice.

* If any percentage, complete the Intellectual Property and/or Securities Supplemental Applications.

b. Does the engagement letter include the following:

If “yes”, complete the Fee Suit Supplemental Application.

If “yes”, please complete the Client Information supplement.

If “yes” complete the Mass Tort / Class Action Supplemental Application.

35. After inquiry, is any attorney in the firm aware of:

If “yes” to a, or b above complete the Claims Supplemental Application for each claim or incident.

If “yes” to a or b above complete the Disciplinary Supplement unless the matter was reported under a prior CNA policy term and supplement was completed. The Disciplinary – Status Update Supplement should be completed for renewal policies where the matter was previously reported but was still open at the last renewal.

(Some limits / deductibles / optional coverages may not be available in all states and all are subject to underwriting qualification. Your quote will reflect the coverage and options for which your firm qualifies.):

NOTE: The Title Insurance Agency optional coverage extends coverage to a specific title agency as a separate entity. A supplemental application is required.

Applicant hereby represents, after inquiry, that the information contained herein and in any supplemental applications or forms required hereby, is true, accurate and complete and that no material facts have been suppressed or misstated. Applicant acknowledges a continuing obligation to report to the Company as soon as practicable any material changes in all such information, after signing the application and prior to issuance of the policy, and acknowledges that the Company shall have the right to withdraw or modify any outstanding quotations and/or authorization or agreement to bind the insurance based upon such changes. 

 

Further, Applicant understands and acknowledges that:

1. If a policy is issued, the Company will have relied upon, as representations: this application, and any supplemental applications,and any other statements furnished to the Company in conjunction with this application, all of which are hereby incorporated by reference into this application and made a part hereof.

2. This application will be the basis of the contract and will be incorporated by reference into and made part of such policy; and

3. Applicant’s failure to report to its current insurance company, during the current policy period, either any claim made against any insured, or any act or omission known to any insured that may reasonably be expected to be the basis of a claim against any insured may create a lack of coverage.

4. Any attorney currently or formerly affiliated with the firm or any predecessor firm, has disclosed in this Application any actual or alleged, act, omission, circumstance or breach of duty that a reasonable attorney would recognize might reasonably be expected to result in a claim being made against the firm, any predecessor firm, or any attorney currently or formerly affiliated with the firm or  any predecessor firm, regardless of whether any such claim would be meritorious. 

Applicant hereby authorizes the release of claim information to the Company from any current or prior insurer of the Applicant.

FRAUD NOTICE – WHERE APPLICABLE UNDER THE LAW OF YOUR STATE

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 MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES (for New York residents only: and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.) (For Pennsylvania Residents only: Any person who knowingly and with intent to injure or defraud any insurer files an application or claim containing any false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to seven years and payment of a fine of up to $15,000.) (For Tennessee Residents only: Penalties include imprisonment, fines and denial of insurance benefits.)