INSTRUCTIONS

1. Answer ALL questions and submit copies of all information where requested. Incomplete applications will result in a delay in obtaining a quotation. NO MEMBERSHIP DUES ARE REQUIRED.

2. A COPY OF THE CURRENT CLIENT ELIGIBILITY GUIDELINES MUST BE SUBMITTED WITH YOUR SIGNED ORIGINAL OF THIS APPLICATION.

3. In responding to Question #12, list the current and projected staff of your organization and indicate the title of each individual (i.e. executive director, lawyer, volunteer attorney, managing attorney, staff attorney, law student, paralegal, etc.). The executive director position must be listed regardless of whether that individual is an attorney. Projected positions should be indicated by using the term "To Be Filled". This is important to ensure that you are provided with an accurate premium quotation. PLEASE NOTE THAT A REDUCTION OF PERSONNEL WILL NOT RESULT IN RETURN OF PRO RATA PREMIUM DURING THE POLICY YEAR.

4. If you need to clarify any of the answers to any question, please send an addendum with your signed original of this application.

5. If you answer "Yes" to Question #8 of Section I, please be certain to fill out the Pro Bono Questionnaire section.

6. If you answer "Yes" to Question #9 of Section III, please be sure to provide descriptions.


SECTION I

Does your organization receive any LSC (Legal Services Corporation) funding? YES NO


1. Name of Organization:


Street Address:


City: County: State: Zip:

Phone: Fax:

Your Email:

Your Website:

Mailing Address (if different from above):

Date established (MM/DD/YYYY):

2. List Branch Offices and Addresses, if any:


3. Type of Organization (Describe the purpose, general operations and functions of your Organization - if your Organization is strictly a pro bono or judicare Organization, please describe your operations under Question 8 below).


4. Total number of cases and/or files handled or processed annually. (An estimate may be used if an accurate count is not available.)

5. Does the Organization accept cases for clients who are not indigent and whose incomes are above the national poverty level? (Written guidelines for client eligibility MUST be sent with your signed original of this application.) YES NO

6. If fees for services have been established by your Organization, please specify the type of case and the maximum fee charge presently used for each type of case (excluding registration fees and court costs). If no fees are charged, insert "Not Applicable".

7. Does your Organization provide services other than legal (social, medical, recreational or other)? YES NO

If YES, please give full particulars:


8. Does your organization utilize the services of attorneys outside of your Organization on a pro bono, judicare or contract basis? YES NO

If YES, please answer the questions below:

(a) Screening and referral is performed by:

(b) Types of matters referred:

(c) Number of pro bono/judicare panel attorneys:

Number of pro bono/judicare cases referred annually:

Number of attorneys accepting reduced-fee referrals (fee paid by client):

Number of reduced-fee referrals annually (send fee schedule):

Number of contract attorneys:

Number of cases handled on a contract basis:


(d) Does your organization check to see if the participating attorneys are admitted to practice law in your state? YES NO

(e) Does your organization check to see if the participating attorneys have had any legal malpractice or disciplinary complaints filed against them? YES NO

(f) Does your organization inform the client and the participating attorney of the terms and conditions of the referral (e.g. the termination of representation by your organization)? YES NO

(g) Please describe your organization's monitoring and follow-up procedures:


9. Describe your Organization's practice of law by showing approximate percentages of cases involving the following: (Total should equal 100%)

% Divorce/Family Law
% Real Estate
% Bankruptcy
% Landlord / Tenant
% Wills/Estate Work
% Public Benefits Law (Social Sec., UC, Workers Comp, Medicare)
% Guardianships
% Criminal
% Juvenile
% Corporate
% Bodily/Personal Injury Plaintiff
% Bodily/Personal Injury Defendant
% Labor
% Environmental Law
% Immigration
% Housing Law
% Bonding Issues (and related work)
% Advocacy for Developmentally and/or Mentally Disabled Persons
% Child/Spouse Abuse
% Services to farmers regarding creation, adjustment, restructuring or discharge of indebtedness secured by farm real estate or crops
% Other - Please specify and describe fully:


10. Does your Organization provide legal services to groups, corporations or associations? YES NO

If YES, please provide detailed description (types of groups/corporations/associations, specific legal services provided, etc.)

11. If you have answered YES to Question 10, please indicate whether the group, corporation or association is primarily composed of persons eligible for legal aid services and whether such group, corporation or association has provided information showing it lacks and has no practical means of obtaining funds to retain private counsel.

12. Please indicate position after the name of each individual listed and whether the individual is salaried or volunteer and part-time or full-time. Please also indicate if any of the individuals listed above are located in states other than where the main office is located.

LAWYERS, LAW STUDENTS, PARAPROFESSIONALS


13. Is your organization an ACLU that utilizes the services of cooperating volunteer attorneys outside of your organization? YES NO

If YES, please advise maximum number of such attorneys and maximum number of cases handled:

14. Does your organization permit attorneys to engage in uncompensated outside practice of law as defined in Section 1604.5(b) and (c) of the Legal Services Corporation regulations? YES NO

15. Has any claim, suit, charge, investigation or proceeding ever been made or instituted against the Organization or any Lawyer or other person providing professional services on behalf of the Organization which (Please respond below):

Seeks an injunction or functionally similar order (including but not limited to a restraining order, a writ of mandamus, a writ of prohibition or an order compel prosecution)? YES NO

Alleges any of the following types of conduct listed below:

(a) Negligent acts or omissions in the course of rendering professional services as a Lawyer, under the direction of a Lawyer, or Notary Public? YES NO

(b) Attorney misconduct or breach of professional ethics? YES NO

(c) False arrest, detention or imprisonment or malicious prosecution?YES NO

(d) Publication or utterance of a libel or slander or of any other defamatory or disparaging material or publication or utterance in violation of an individual’s right of privacy? YES NO

(e) Wrongful entry or eviction, or other invasion of the right of private occupancy? YES NO

(f) Conduct for which the claimant seeks an award of punitive or exemplary damages? YES NO

(g) Violation of a federal, state, municipal or local criminal statute or law? YES NO

(h) Conduct which may give rise to a contempt proceeding? YES NO

(i) Any conduct in connection with the employment, hiring, failure to hire, discharge or termination of the employment of an employee, former employee or application for employment? YES NO

(j) Conduct of Directors/Officers and/or other management personnel alleging negligence in their official capacity as management? YES NO

16. Does the Organization or any person specified in response to Question 12 know of any circumstance, act, error, omission or inquiry that could result in a claim, suit, charge, investigation or proceeding against the Organization or any Lawyer or other person providing professional services on behalf of the Organization that seeks an injunction or functionally similar order or is based on any of the types of conduct described in Question 15 above? YES NO

If YES, please provide the name of the Lawyer or other person involved and all other pertinent details:

17. Current Lawyers Professional Liability Insurance (must be answered in full):

(a) Carrier:
(b) Limits of Liability:
(c) Deductible:
(d) Policy Expiration Date:
(e) Premium $
(f) Retroactive Date:
Please send a copy of your current policy with your signed original of this application.

18. Does you organization provide legal services to farmers regarding the creation, adjustment, restructuring or discharge of indebtedness secured by farm real estate or crops? YES NO

If YES, please provide details:


If YES, do you charge fees to the recipient client directly for the services rendered? YES NO



SECTION II - DATE, CALENDAR OR DOCKET CONTROL AND INTERNAL PROCEDURES

1. Does your Organization...

have at least two independently maintained calendars on which litigated and non-litigated items are entered by separate individuals? YES NO

AND are the calendars cross-checked at least weekly by separate individuals responsible for cross-checking? YES NO

AND does ultimate responsibility for docket control rest with the attorney responsible for the case? YES NO

If any of the above answers are NO, please explain below:

2. Does your organization use a computer-driven calendar and docket control system? YES NO

Name of software program:


3. If your organization becomes aware of a conflict, do you disclose it in writing to all parties? YES NO

If NO, please explain:


4. Does your Organization have written procedures for identifying potential or actual conflicts of interest? YES NO

If NO, please explain:


5. How does your Organization avoid conflicts of interest? Oral/Memory Index file Computer Conflict Committee Other (please specify):

6. Does your Organization generate engagement letters for all its clients? YES NO

7. Does your Organization notify clients in writing when your services are completed and when a relationship is terminated? YES NO

If NO, please explain:

8. Does your Organization notify clients or prospective clients in writing when you decline to represent them? YES NO

If NO, please explain:

9. Does your Organization have an internal grievance procedure to address complaints by clients? YES NO

If YES, please explain:


SECTION III

1. What constitutes the management of the Organization? (Trustees, Directors' Committee, Titles of Officers, etc.)

2. How is Management selected?

3. Staff

Salaried:
Number of officers and/or directors (including Executive Director):
Number of Staff members (not including clerical employees):
Number of clerical employees:

Non-Salaried:
Number of officers and/or directors (including Executive Director):
Number of Staff members (not including clerical employees):
Number of clerical employees:

Is the Executive Director full-time or part-time? Full-time Part-time

4. Is the Organization a Not-for-Profit corporation chartered in its state of domicile? YES NO

If NO, Please explain its status:


5. Is the Organization directly in the insurance agency or brokerage business in any way? YES NO

If YES, please explain:


6. Is your Organization unionized? YES NO

7. Does your organization have an internal grievance procedure to address complaints by employees? YES NO

If YES, please explain:


8. Does the Organization publish any publication for limited or general distribution? YES NO

If YES, please send with your signed original of this application.

a. As to each publication, state its purpose, general content, frequency of publication and amount published:


b. State the name of the officer or employee who reviews each publication prior to its distribution:


9. Does the Organization sponsor any private or public meetings or conventions? YES NO

If YES, state number and frequency:


10. Total Annual budget (all sources) Year:

LSC (Legal Services Corporation) Budget:
IOLTA:
Title XX:
United Way:
Older Americans Act:
Other Sources*:
= TOTAL BUDGET:

*Please identify other funding sources:

PRO BONO ENDORSEMENT OPTIONS

For organizations utilizing the services of attorneys outside of the organization on a Pro Bono, Judicare, and/or Contract Basis.

If you answered YES to Question 8 in Section I of the Application for Insurance, you can extend coverage for your organization and your outside attorneys. Please select one of the endorsement options below, and your quotations will include the premium for the endorsement you select.

STANDARD PRO BONO/JUDICARE FOR ATTORNEYS AND CASES: Provides coverage to your organization for the referral of legal aid eligible clients/cases to participating pro bono/judicare/contract attorneys. Coverages A1, A2, A3, and A4 will also extend to the participating attorneys handling the pro bono/judicare cases referred by your organization. This coverage is secondary to any other valid and collectible insurance available to such attorneys. YES NO

PRIMARY PRO BONO/JUDICARE FOR ATTORNEYS ONLY: The same as Standard above except that the coverage would be considered Primary and all other insurance would be considered in excess thereto. YES NO

PRIMARY PRO BONO/JUDICARE FOR ATTORNEYS AND THEIR EMPLOYER FIRMS: The same as Standard above except that the coverage would be considered Primary and all other insurance would be considered in excess thereto. In addition, the coverage would extend to any law firm, corporation, or other organization which an attorney accepting a case is an employee or member of. Coverage for the employer firm would be limited solely with respect to liability arising from the participation of the attorney in the pro bono/judicare program. YES NO

REFERRALS ONLY COVERAGE: Provides your organization with coverage for referral of eligible clients to a pro bono/judicare program outside of your organization. There is no coverage for any attorney accepting the referral. YES NO

We do not wish to carry any pro bono endorsement.YES NO

IMPORTANT!
In the event that a claim or claims or any circumstance, act, error, omission or inquiry that could result in a claim against the Organization or the persons named in this application have been reported to Underwriters or disclosed on this application, or if the Organization charges fees for its services, or if the Organization does not utilize income eligibility guidelines for clients, Underwriters reserve the right to individually rate insurance for the above Organization.

It is understood that the insurance applied for will issue on the 1st day of the month following receipt of the premium and the acceptance of the application by Underwriters. I/We hereby declare, based upon my/our knowledge and upon reasonable investigation, the above statements are true and that I/We have not suppressed or misstated any material facts and this application shall be the basis of the contract with Underwriters at Lloyd's, London.

Please be advised that an original, signed and dated application is required in order to bind coverage.

SUBMITTING THIS FORM DOES NOT BIND THE APPLICANT OR THE UNDERWRITERS TO COMPLETE THE INSURANCE.

A signed and dated original of the application will be required in order to bind coverage. A copy of your application will be included with your quotation for your signature.

UNDERWRITERS REQUIRE A MINIMUM OF 14 DAYS TO REVIEW AND QUOTE ASSUMING ALL REQUIRED INFORMATION FOR QUOTING HAS BEEN SUPPLIED.

This policy does not cover Private Law Practice. This is an application for Claims Made Insurance.


A copy of this application will be included with your quotation and MUST be SIGNED in ink by the Executive Director or Deputy Director. One signed copy will be attached to and form part of the Policy or Certificate, if issued.


Please enter name of person submitting this form (MUST be entered):

Please enter the date you are submitting this form (MUST be entered):