NBA

NATIONAL BAR ASSOCIATION

 

Servicing Agency GARY FINANCIAL GROUP

SHORT FORM APPLICATION FOR LAWYERS PROFESSIONAL LIABILITY INSURANCE AND RISK MANAGEMENT PROGRAM 

This Short Form Application is only for the purpose of providing a rough, non-binding indication. All terms and conditions indicated as a result of this application are subject to amendment upon receipt of a Full Application.  The receipt of a satisfactory, completed signed and dated Full Application is a precedent to any binding terms being provided by Underwriters hereon.
Name of Applicant
Phone:
Fax
Address (County/State)
Total number of Lawyers: This Year
Last Year
Partners/Shareholders
Employed Lawyers/ Associates
Of Counsel
Other Staff
Total Gross Billings (whether collected or not, including contingent fees) by Fiscal Year:

This Year

Last Year

Indicate Percentage of this year’s “Total Gross Billings” derived from:
(OVERALL TOTAL MUST EQUAL 100%)
AREA OF LAW LAST YEAR THIS YEAR
Banking/Savings & Loan % %
BI/PD & Personal Injury Litigation (Defense) % %
BI/PD & Personal Injury Litigation (Plaintiff) % %
General Corporate Advice/Litigation % %
Corporate/Partnership Formation/Alteration % %
Real Estate % %
Securities Practice including Syndications/Bonds/Tax Shelters/Ltd. Partnerships and Derivatives % %
Taxation % %
Environmental % %
Bankruptcy % %
Copyright/Patent   % %
Estate/Trust/Probate % %
Municipal Law (Except bonds) % %
Domestic Relations % %
Admiralty Law (except Labor Relations) % %
Criminal   % %
Labor Relations % %
Entertainment   % %
Oil & Gas % %
Other   % %
Please describe:
Overall Total (must equal 100%) % %

Number of Claims and/or circumstances in past five years:
Total Amount Paid (inc. Defense)
Total Amount Reserved (inc. Defense
Is the Applicant aware of any incidents, which may result in a claim against the Applicant
Continuing Education:
Have all attorneys in your firm had some type of continuing legal education in the past year? Yes  No
Docket System:
How many independent date controls are kept?
How often are they crosschecked?
Internal Procedures:
Do you have a conflict of interest procedure? Yes  No
Do you use client communication letters? Yes  No
How many suits for fees have you filed in the last two years?
Your Claims History:
Have any disciplinary actions been taken against any attorney in the last three years? Yes  No
Have you reported any claims in the last five years? Yes  No
If yes please provide explanation:
Current Carrier:
Limit:
Limit Requested:
Deductible:
Retro date:
Deductible Requested:
Premium:
Each Claim/Aggregate
(delete as applicable)

The Applicant declares and warrants that, after inquiry, to the best knowledge of all persons to be insured the statements set forth herein and in any attachments made hereto are true and no material facts have been suppressed, omitted or misstated.  Underwriters reserve the right to deny or rescind coverage on any Policy that is issued as a result of this Application if, in the statements set forth and in any attachments made hereto, it is found that material information has been omitted, suppressed or misstated. Signing this Application does not bind the Applicant or Underwriters to complete the Insurance, but it is agreed that the statements and particulars contained herein will be relied upon by Underwriters should a policy be issued.
This Application is Filled in and submitted on behalf of all Owners, Partners, Shareholders, Corporate Officers and Employees.

AUTHORIZED APPLICANT
Must be a principal of the Applicant and a person at risk:
TITLE:
Date:
Effective Date Requested: