SECTION I - LAWYERS PROFESSIONAL LIABILITY COVERAGE (Including Notary Public Professional Liability)

First and last name of the person submitting this application:


1. Name of Organization:


Address:


City: State: Zip:

Phone: Fax:

Date Organization Established (MM/DD/YYYY):

Type of Organization: Public Defender Assigned Counsel

Email:

Mailing Address (if different from above):

2. List Branch Offices and Addresses, if any.







3. If fees have been established for your organization, please specify the type of case and the fee schedule presently used (excluding registration fees and court costs). If no fees are charged, insert "Not Applicable."


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

5. Has any professional liability claim or suit ever been made against the Organization or Lawyers listed in response to question 9? YES NO

If YES, give the name of the Lawyer or other person involved, name of claimant, date and disposition of the case.


6. Does the Organization or any lawyer listed in response to question 9 know of any circumstance, act, error, omission or personal injury that could result in a professional liability claim against him/her or the Organization named in the application? YES NO

If so, please give full details:


7. Has any Notary Public errors and omissions claim ever been made against the Organization, any individual listed as a Lawyer/Law Student/Paraprofessional under question 9 or against any other individual providing services on behalf of the Organization? YES NO

If YES, give the name of the individual involved, name of claimant, date and disposition of case.

8. Does the Organization or any individual providing services on behalf of the Organization, know of any circumstance, act, error, omission or personal injury that could result in a Notary Public errors and omissions claim against him/her or the Organization? YES NO

If YES, give name of possible claimant, date of act and other details.

9. List ALL Lawyers (including part-time salaried and volunteer lawyers), law students and paraprofessionals including those projected for policy period. Use the word "VACANT" in each category for projected employment of lawyers and law students/paraprofessionals. New employees will be covered at no additional cost, but reduction of personnel will not result in return of pro-rata premium during the policy year. When a large turnover in personnel occurs, you may approximate the number of Lawyers and/or Law Students by using the highest number employed at any one time during the year.

LAWYERS*

*Indicate if part-time (PT) or volunteer (V)

LAW STUDENTS/PARALEGALS


Does your organization use the services of attorneys, paralegals or investigators outside of your organization on an appointment or contract basis? YES NO

A. Number of panel attorneys:
B. Number of cases referred annually to panel attorneys:
C. Number of contract attorneys:
D. Number of cases referred annually to contract attorneys:
E. Number of paralegals: by contract on panel
F. Number of panel attorneys: by contract on panel
G. Describe your procedure for monitoring and removing attorneys, paralegals or investigators:


10. Describe your Organization's practice of law by showing approximate percentage of cases involving criminal matters:

% Appeals
% Felonies
% Juvenile
% Mental Commitment
% Misdemeanors
% Other Criminal (specify):

If your practice of law includes civil matters*, please indicate the approximate percentage of cases involving the following:

% Child/Spouse Abuse
% Conservatorships
% Juvenile Dependency
% Juvenile Delinquency
% Guardianships
% Guardian ad Litem
% Other Civil (specify):

(Total of all of the above should equal 100%)
*Underwriters reserve the right to individually rate insurance for the Organization if the Organization's practice includes civil matters.

SECTION II - MANAGEMENT ERRORS & OMISSION COVERAGE and EMPLOYMENT PRACTICES COVERAGE

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


What officers are provided?

How is the management selected?

2. Number of officers and/or directors: Salaried Non-Salaried
Number of staff members: Salaried Non-Salaried
Number of clerical employees: Salaried Non-Salaried
Is the Executive Director full time or part time? Full time Part time

3. Is the Organization a Not-For-Profit corporation, chartered in the state of domicile? YES NO

If NO, please explain its status

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

If YES, please explain

5. Does the Organization publish any publication for limited or general distribution? State the purpose, general content, frequency and amount of each publication and the individual who reviews each publication prior to its distribution.

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

If YES, please state the number and frequency

7. During the past 10 years has there ever been a liability claim made against the Organization or its management personnel? YES NO

If YES, please explain.

8. Is the Organization aware of any circumstance, act, error, omission or personal injury that could result in a liability claim against the Organization or any of its past or present directors, officers, or employees? YES NO

If YES, give name of possible claimant, date of act and other details.

9. Has any claim or suit or charge before any government agency concerning the employment practices of the Organization been made against the Organization or any of its past or present directors, officers, or employees by an employee, former employee or prospective employee? YES NO

If YES, please give details

10. Is the Organization aware of any circumstance, act, error or personal injury that could result in a claim, suit or charge before any government agency being made against the Organization or any of its past or present directors, officers, or employees by an employee or prospective employee concerning the employment practices of the Organization? YES NO

If YES, give name of possible claimant, date of act and other details.

SECTION III - DISCIPLINARY PROCEEDINGS COSTS COVERAGE
(This section MUST be completed to obtain the basic Professional Liability quotation)

1. Has any Disciplinary Proceedings (attorney misconduct) claim ever been made against the Organization, any individual listed as a Lawyer/Law Student/Paraprofessional on the Lawyers Professional Liability Insurance application or against any other individual providing services on behalf of the Organization? YES NO

If YES, give the name of the individual involved, name of claimant, date and disposition of case.

2. Does the Organization or any individual providing services on behalf of the Organization know of any circumstance, act, error, omission or personal injury that could result in a Disciplinary Proceedings (attorney misconduct) claim against him/her or the Organization? YES NO

If YES, give name of possible claimant, date of act and other details.

SECTION IV - CRIMINAL DEFENSE COVERAGE
(This section MUST be completed to obtain the basic Professional Liability quotation)

1. Has any claim, suit, charge, investigation or proceeding ever been made or instituted against the Organization, its Management, or any Lawyer or other person providing professional services on behalf of the Organization which alleged violation of a federal, state, municipal or local criminal statute or law? YES NO

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

2. Does the Organization, its Management, or any person specified in response to Section I, Question 9 of the application know of any circumstance, act, error, omission or injury that could result in a claim, suit, charge, investigation or proceeding against the Organization, its Management, or any Lawyer or other person providing professional services on behalf of the Organization based on an alleged violation of a federal, state, municipal or local criminal statute of law? YES NO

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

SECTION V - CONTEMPT DEFENSE COVERAGE
(This section MUST be completed to obtain the basic Professional Liability quotation)

1. Has the Organization or its Management, or any Lawyer or other person providing professional services on behalf of the Organization, ever been the subject of criminal or civil contempt proceedings, or cited for criminal or civil contempt, by any court, administrative agency or governmental body? YES NO

If YES, please provide the name of the management official, Lawyer or other person involved, the disposition of the matter and all other pertinent details.

2. Does the Organization, its management officials, or any lawyer or other person providing professional services on behalf of the Organization, know of any incident, circumstance, act, error, or omission that could result in the initiation of criminal or civil contempt proceedings, or the imposition of a contempt citation, against the Organization or any such management official, Lawyer or other person? YES NO

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


IMPORTANT

In the event that a claim or claims or any circumstance, act, error, omission or personal injury that could result in a claim against the Organization or the persons named in the application have been reported to Underwriters or disclosed on the application, or if the Organization's practice includes civil matters, Underwriters reserve the right to individually rate insurance for the above Organization.

The applicant declares that based upon his knowledge and upon reasonable investigation, the statements and particulars contained herein are true and complete, and that no material facts have been suppressed or misstated. The applicant acknowledges that this application shall be the basis of a contract with Underwriters at Lloyd's, London, and that the insurance applied for will issue on the 1st day of the month following receipt of the premium and acceptance of the application by the insurer.

** 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 person completing the application. 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):