INSTRUCTIONS: Answer ALL questions fully. If the answer to any question is None or Not Applicable, please state "NO".

First and last name of the person submitting this application:


1. Full name of insured:


Address:


City: State: Zip:

Phone: Fax:

Your Email:

Mailing Address (if different from above):

2. Type of business: Corporation Partnership Individual

Date established (MM/DD/YYYY):

Business Phone:

3. Has the type of business changed in the last 5 years? YES NO

4. Has the name of firm been changed during the past 5 years? YES NO

If so, please give particulars:


5. List the names of all predecessor firms of applicant:


6. List the names of all attorneys providing professional services on behalf of the applicant:


7. List the names of all Partners, Directors, Owners, age, law school graduated from, date of admission to the Bar, and specialty:

Name	Age	Law School	Date Admitted To Bar	Specialty

8. List the names of all Employed Lawyers not listed in question 7, their age, law school graduated from, date of admission to the Bar, and specialty:

Name	Age	Law School	Date Admitted To Bar	Specialty

9. Total number of attorneys:

10.State the number of: (Individual coverage is not provided for persons listed herein)

(a) Law Clerks
(b) Investigators
(c) Secretarial & Office Help
(d) Accountants
(e) Abstractors
(f) Paralegal personnel

11.If Applicant is sole practitioner, state:
(a) Whether you are engaged in independent private practice YES NO
(b) Does the applicant provide professional services as an attorney on behalf of any other attorney or firm? YES NO
If yes, please provide the name of that attorney or firm.

(c) Please provide the name of a specific attorney or firm who will be responsible for your affairs should you be absent for an extended period of time (i.e. business trip, vacation, illness, etc.) This question must be answered if you are a sole practitioner.

12.Does any lawyer named in Questions 6, 7, & 8 have any other law partner, associate, or employed lawyer other than those in Questions 6, 7, & 8? YES NO
If so, please provide full details:


13.Does any lawyer named in Questions 6, 7, & 8 share office space with any lawyer NOT NAMED in Questions 6, 7, & 8? YES NO
If so, please provide full details:


14.Describe your practice by first showing approximate amount of time devoted to the following:
% Court Appointed Criminal Defense
% Privately Retained Criminal Defense
% (a) Total Criminal Defense
% (b) Total Other
100% (c) Total Areas of Practice (a+b)

Describe "OTHER" below by showing percentages of time devoted to the following: (Your answers should equal the percentage shown above in 14. b)

% Admiralty/Maritime
% Banking
% Collection/Repossession
% Communication (FCC)
% Defendants Litigation Civil
% Domestic Relations
% Estate Planning**
% Estate/Probate/Trust**
% General Commercial
% General Corporation
% International Law
% Oil and Gas
% Patents, Copyrights, TM
% Plaintiffs Litigation
% Plaintiffs Litigation BI/PI
% Public Utilities
% Real Estate (Commercial)
% Real Estate (Residential)
% S.E.C. Law and/or Regulations
% Taxation**
% Other - Please specify and describe fully:


** If your type of work includes Estate Planning, Estate/Probate/Trust Taxation, you must complete the following section (otherwise, skip to Question 15). PLEASE NOTE: Questions (1) through (7) below are a supplement to the application, and you will be required to sign a copy indicating that you understand the information contained in the supplement will become part of the Lawyers Professional Liability Application and is subject to the same representations and conditions.


(1) Has the applicant rendered legal opinions regarding the legality, appropriateness or efficacy of any tax benefit transactions, tax treatment, tax strategy or tax shelters within the past five years? YES NO

(2) If the answer to question (1) is yes, has the applicant made a determination as to whether any of the transactions that are the subject of such opinions constitute listed or reportable transactions within the meaning of Sections 6011 or 6112 of the Internal Revenue Code? YES NO

(3) If the answer to question (1) is yes, were the fees or other compensation charged or received by the applicant in connection with any such opinion based solely upon its customary hourly rates for legal services? YES NO

If not, please describe the manner in which the fees or other compensation charged or received by the applicant in connection with any such opinion were calculated.


(4) Is the applicant aware of whether the IRS, US Treasury Department, or any state or local taxing authorities have released any notices, opinions, announcements, regulations, or revenue rulings, or any other published guidance, regardless of form, in the past five years, in which they question, change, prohibit or negatively discuss a tax treatment or strategy that formed the basis for the applicant's opinion to a client or clients? YES NO

If the response to this question is yes, please provide the number of such instances and details regarding the disposition of each situation.


(5) Within the past five years, has the applicant discontinued the issuance of or withdrawn an opinion or opinions on a tax treatment or strategy following the release of any notices, opinions, announcements, regulations or revenue rulings by the IRS, the US Treasury Department or any state or local taxing authorities? YES NO

If the response to this question is yes, please provide the number of such instances and details regarding each situation.


(6) Within the past five years, has the applicant issued tax opinions on tax treatments or strategies, where similar or related tax treatments or strategies previously have been questioned or prohibited by the IRS, the US Treasury Department or any state or local taxing authorities? YES NO

If the response to this question is yes, please provide the number of such instances and details regarding each situation.


(7) Within the past five years, has the applicant received a subpoena or other request for information (including but not limited to an administrative summons or promoter summons), whether formal or informal, from the IRS, the US Treasury Department or any state or local taxing authority in connection with the applicant's role in any tax benefit transactions, tax treatment or tax strategy implemented by or on behalf of any of its clients? YES NO

If the response to this question is yes, please provide the number of such instances and details regarding the disposition of each situation.


(8) Within the past 5 years has the applicant referred any client to any other professional entity to provide any services that are referred to in this Questionnaire? YES NO

If the response to this question is yes, please provide the number of such instances and details regarding each situation.



ALL APPLICANTS PLEASE CONTINUE HERE:



15. Give details of legal work performed in a fiduciary capacity by the firm or any individual lawyer during the past three years:


16. Is the applicant currently insured under a Claims Made professional liability policy? YES NO

17. How long has the applicant maintained continuous claims made insurance coverage?

18. Please give full particulars of all similar insurances carried during the past five years:

Insurer	Premium	Limits of Liability	Deductible	Period	Form
					Claims Made Occurrence
					Claims Made Occurrence
					Claims Made Occurrence
					Claims Made Occurrence
					Claims Made Occurrence

19. Has any professional liability insurance for the applicant, present Partner or predecessors or any lawyer in the firm ever been declined or cancelled, refused to be renewed? YES NO

If so, please give full details:


20. After inquiry of each lawyer in the firm, has any lawyer in the firm ever been reprimanded by, or refused admission to practice, disbarred, or suspended from practice before any court or administrative agency or been subject to disciplinary actions? YES NO

If so, please give full details:


21. After inquiry of each lawyer in the firm, have any claims or suits ever been made against any lawyer in the firm, or their predecessors in business? YES NO

If so, please give full details:


22. After inquiry of each lawyer in the firm, does any lawyer in the firm know of any circumstances, act, error, omission or personal injury
that could result in any claim being made against him/her or, their (his/her) predecessors in business or any of the present or past partners? YES NO

If so, please give full details:


23. DOCKET CONTROL - (Calendars, Tickler Systems, etc.) Please provide details of system, including explanation of date controls used in your office and who has responsibility for entry of items assigned.


24. Applicants approximate gross billable dollars for the past 12 months are:
Under $50,000
$50,000 to $100,000
$100,000 to $150,000
$150,000 to $250,000
$250,000 to $500,000
$500,000 to $1,000,000
$1,000,000 & over

25. Does Applicant's practice also involve acting in the capacity of any of the following? YES NO

If yes, indicate the percent of practice devoted to each and whether separate professional liability insurance is carried for this work:
(a) Insurance agent or broker
(b) Accountant
(c) Real Estate agent or broker
(d) Title abstractor
(e) Title agent

26. Is the applicant or any Partner or Lawyer of the Firm a salaried employee, partner, officer, director or
owner of any organization other than the Firm? YES NO
If so, please give full details:


27. Please provide the following information:
INSURANCE REQUESTED
(a) Limits of Liability requested:
$100,000/$300,000
$250,000/$500,000
$500,000/$500,000
$1,000,000/$1,000,000
$1,000,000/$2,000,000
$2,000,000/$2,000,000

(b) Deductible requested:
$1,500.00 (minimum)
$2,500.00
$5,000.00
Other:

(c) Retroactive Date of Current Policy:*
(d) Proposed effective date for this insurance:

* Retroactive Date: You may request the same Retroactive Date that is on your present policy if you have had continuous
"claims made" coverage since that date. If you are not currently covered by a "claims made" Lawyers Professional Liability
Insurance Policy, then your Retroactive Date will be at Inception, which means no coverage will be afforded for any acts,
errors or omissions committed, in whole or in part, prior to the Inception Date of any policy issued by Underwriters.

28. Are you a member of the National Association of Criminal Defense Lawyers? YES NO

NOTICE TO APPLICANT:

WARRANT: I/We warrant that the information contained herein is true and that it shall be the basis of the policy of insurance and deemed incorporated therein, should the Underwriters evidence their acceptance of this application by issuance of a policy.
I/We hereby authorize the release of claim information from any prior insurer to Underwriters.

NOTE: In applying for coverage, the applicant agrees that in the event of covered losses, he will be required to be defended by the Underwriters' appointed lawyers, and that the deductible shall apply to loss and claim expenses, adjusting expenses, investigation costs, and legal fees. If the applicant elects to handle a claim without in any way involving the Underwriter, then no coverage for such claim is afforded the applicant under the policy.

I understand and accept that the policy applied for provides coverage on a CLAIMS MADE basis for ONLY THOSE CLAIMS FIRST MADE AGAINST THE INSURED WHILE THE POLICY IS IN FORCE and that coverage ceases with the termination of policy unless I exercise options available and in accordance with terms of the policy.

** SUBMITTING THIS FORM DOES NOT BIND THE APPLICANT OR THE UNDERWRITERS TO COMPLETE THE INSURANCE.
A copy of this application will be included with your quotation and MUST be SIGNED in ink by the applicant or a partner of the Firm. One signed copy will be attached to and form part of the Policy or Certificate, if issued.
Please enter the date you are submitting this form (MUST be entered):