This completed document should be submitted to:
Old Republic Professional Liability, Inc.
191 North Wacker Drive, Suite 1000
Chicago, IL 60606-1905
T: 312.750.8800	www.oldrepublicpro.com

APPLICATION FOR
LAWYERS PROFESSIONAL LIABILITY INSURANCE

THIS IS AN APPLICATION FOR INSURANCE WRITTEN ON A CLAIMS MADE AND REPORTED
BASIS WITH DEFENSE COSTS INCLUDED WITHIN THE LIMIT OF LIABILITY

APPLICANT PROFILE

Please answer all questions on this application.  If there is insufficient space to complete an answer, continue on a separate sheet.  This application must be dated and signed by a partner or officer of the firm. 

APPLICANT PROFILE

1.	Name of firm:   	     
								
	Street address:   	     
											
	City/State/Zip Code:	     

	Contact Person:	     

	Telephone No: 	          	Email:       

2.	The firm was first established on      .  (Mo/Day/Yr)

3.	List the names of all predecessor firms whose assets and liabilities the firm is the majority successor in interest.  Include the date each predecessor firm was established and the date of merger.

 	Name of Predecessor Firm	Date Established	Date of Merger
	     	     	     
	     	     	     
	     	     	     

4.	List the address of each branch office and the date it was established:

	Address of Branch Office	Date Established
	(a) 	     	     	
	(b)	     	     	
	(c)	     	     	

5.	Indicate the total number of personnel by location (match branch office personnel with the branch offices listed in question 4.	

		Principal Office	   Branch Office (a)	Branch Office (b)	Branch Office (c)

	Partners or Officers	     	     	     	     	
	Associates/Employed Lawyers	     	     	     	     
	Lawyers "Of Counsel"	     	     	     	     
	Contract Lawyers	     	     	     	     
	Paralegals or law clerks	     	     	     	     
	Other clerical staff	     	     	     	     

LIST ON A SEPARATE SHEET THE NAMES OF ALL LAWYERS IN THE FIRM. INDICATE FOR EACH LAWYER HIS OR HER DESIGNATION IN THE FIRM, BAR AFFILIATION, THE DATE OF ADMISSION TO THE BAR AND THE DATE THEY JOINED THE FIRM.

6.	How many lawyers have joined the firm during the past 12 months?			     

	How many lawyers have left the firm during the past 12 months?			     

7.	Has the firm ever closed a branch office or had a group departure of five or more lawyers during the past three years?
 Yes    No.  If yes, provide full details: 

     
     

8.	Does any lawyer in the firm serve as a director, officer, general counsel, trustee or partner of, or exercise any fiduciary control over, any organization, which is also a client of the firm?  (  ) Yes  (  ) No.  If yes, list the lawyer's name, the name of the organization, the nature of the organization's business and the position held.

	Name of Lawyer	Name of Organization	Nature of Business	Position Held
	     	     	     	     
	     	     	     	     
	     	     	     	     
	     	     	     	     
	     	     	     	     
	     	     	     	     
	     	     	     	     
	     	     	     	     
                                                                                                                                                                                                                                                                                                                                 
9. 	Does the firm own, in whole or in part, any business enterprise whose business activities are outside the practice of law?  
	 Yes    No.   If yes, provide full details: 

	     
     

10. 	Firm's fiscal year ends on: Month:        Day:       .
Indicate the gross income for the applicable fiscal year (gross income means all sums billed to clients for services rendered):

(a)	Actual for second previous fiscal year:     	$0.00
	(b)	Actual for immediate past fiscal year:      	$0.00
(c)	Estimate for current fiscal year:           	$0.00 

11.	Does the firm ever accept securities of a client or other forms of compensation in lieu of fees?  Yes  No.  If yes, provide full details: 

	     
     

PRACTICE PROFILE

12.	Indicate the percentage of gross income for the past fiscal year derived from the following areas of practice:

	
	Area of Practice	
	Administrative Law	     %
	Admiralty/Maritime	     %
	Antitrust/Trade Regulation	     %
	Bankruptcy	     %
	Financial Institution	     %
	Business Transactions and Commercial Law	     %
	Civil Rights and Discrimination	     %
	Collection/Repossession	     %
	Communications (FCC)	     %
	Construction Law	     %
	Corporate and Business Organization	     %
	Criminal Law	     %
	Entertainment/Sports	     %
	Environmental Law	     %
	*Estate, Trust and Probate	     %
	Family Law	     %
	Healthcare	     %
	Immigration and Naturalization	     %
	*Intellectual Property
		Copyright			     %
		Patent			     %
		Trademark			     %
	International Law			     %
	Labor Relations	
		Labor Representation	 	     %
		Management Representation 	     %
	Litigation (Civil)		   		     %

Area of Practice
Local Governmental Law	     %
Oil and Gas	     %
Pension and Employee Benefits	     %
Personal Injury and Negligence:
		Defendant Representation	     %
	*Plaintiff Representation	     %				
*Class Action/Mass Tort Representation   	     %
Public Contract Law	     %
Public Utilities	     %
*Real Property:
		Conveyance	     %
		Development	     %
		Syndication	     %
		Title Examination	     %
*Securities Law	     %
*Tax:
		Opinions/Advice	     %
		Preparation of Tax Returns	     %
Workers' Compensation:
		Defendant Representation	     %
		Plaintiff Representation	     %
Other (list)
 		     	     %
		     	     %
		      	     %

								Total		100%

	For any Area of Practice signified with an asterisk (*), a corresponding Practice Addendum will be required.

13.	Does the firm anticipate any material changes in the percentages shown in question 12. for the period of the proposed insurance? 
	 Yes    No.   If yes, provide full details: 

	     
     

14.	List the five clients which generated the most fees for the firm during the past fiscal year. Indicate the nature of the client's business, the services rendered by the firm using the categories shown in question 12. and the percentage of the firm’s fees they represent:

Name of Client	Nature of Business	Area(s) of Practice	Percentage of Fees

     	     	     	           
     	     	     	      
     	     	     	           
     	     	     	           
     	     	     	           	

15.	Does the firm provide investment advisory services or have discretionary investment authority over the funds of any client?
		 Yes    No.   If yes, provide full details: 

	     
	     

ADMINISTRATIVE SYSTEMS AND PROCEDURES

(firm may elect to provide additional details on a separate sheet in support of a response to any question in this section.)

16.	Management
	(a)	Is the firm managed by a management committee?							 Yes   No
	(b)	How many partners or officers comprise the management committee?	                               
	(c)	Does the firm employ an administrator?						 Yes   No
	(d)	What percentage of the administrator's time is devoted to the practice of law?				     %
	(e)	Does the firm use a peer review system to evaluate the performance of partners or officers?		 Yes   No
	(f)	Does the firm have written document retention procedures?						 Yes   No
	(g)	Does the firm have a written Incident Response Plan for network intrusions and privacy breaches? 		 Yes   No
	(h)	Does the firm have a written Business Continuity Plan for systems recovery in the event of a
		catastrophic event?										 Yes   No
(i)	Check all network and information security controls currently being utilized by the firm:
	Firewall 		Secure Remote Access 		Intrusion Detection Software        	
	Antivirus Software 		Password Protection (all devices) 		Employee Termination Controls  		
(j)	Does the firm encrypt data:	In storage 	    In transit 	      On Mobile Devices 
(k)	Over the past three (3) years, has the firm experienced a security breach requiring notification of 
	customers or other third parties?	If yes, provide full details.						 Yes   No
			
17.	Docket and Calendar
	(a)	Does the firm maintain a planned docket control system and procedure with at least two 
		independent date controls?			 Yes   No								( ) Yes  ( ) No 
	(b)	Is the docket control system and procedure computerized?		 Yes   No
	(c)	Does the planned docket control system and procedure produce a weekly calendar?		 Yes   No
	(d)	Does the planned docket control system and procedure cover all aspects of the firm's practice?		 Yes   No
	(e)	Does the planned docket control system and procedure require lawyers to both calendar 
		and remove from calendar all filing dates?		 Yes   No
	(f)	Are open calendar entries on the planned docket control system and procedure circulated to all 
		lawyers or, if the firm is divided into formal departments, to all lawyers in the appropriate department?	 Yes   No

18.	Training and Supervision
	(a)	Does the firm maintain a formal training program for new lawyers as to office and court procedures?	 Yes   No
	(b)	How many lawyers in the firm have participated in formal continuing legal education programs of at 
		least seven 	hours during the last year?	      
	(c)	Are all associates of the firm under the direct supervision of a partner or officer?				 Yes   No
	(d)	Are all associates of the firm subject to periodic, formalized review?					 Yes   No
	(e)	Does the firm have written risk management procedures that are circulated to all firm employees?		 Yes   No

19.	New Business
	(a)	Are new clients subject to approval of the firm's management committee or at least two partners or officers?	 Yes   No
	(b)	Are background checks conducted on every potential client prior to acceptance?				 Yes   No
(i)	Do background checks include client’s reputation for litigation?					 Yes   No
(ii)	Do background checks include client’s prior representation by another firm?			 Yes   No
	(c)	Is information as to all new clients made available on at least a weekly basis to all partners or officers of the 
		firm?												 Yes   No 
	(d)	Does the firm maintain a system to avoid conflicts of interest?						 Yes   No
	(e)	Is the conflicts system computerized?								 Yes   No
	(f)	If a conflict of interest is identified, does the firm require approval of a committee or at least a 
		non-interested partner to proceed?									 Yes   No
	(g)	Is a lawyer generating new business required to associate with a partner or officer with specific expertise 
		in the matter?											 Yes   No

20.	Outside Communications
	(a)	Is it the firm's standard practice to use engagement and nonengagement letters when agreeing or declining  
		to represent a client?										 Yes   No
	(b)	Is it the firm's standard practice to outline in writing the firm's billing policy and procedures when agreeing  
		to represent a client?										 Yes   No
	(c)	Do major opinion letters have to be approved by at least two partners or officers of the firm?		 Yes   No
	(d)	Do letters to auditors have to be approved by at least two partners or officers of the firm?			 Yes   No

21.	Miscellaneous
	(a)	Does the firm allow its lawyers to practice law outside the firm?					 Yes   No
	(b)	Does the firm have formal, written rules to prevent trading in a client's securities on the basis of non-public 
		information?											 Yes   No 
	(c)	Does service on an outside Board of Directors have to be approved by the firm's management committee or 
		by at least two partners or officers?								 Yes   No 
	(d)	Do suits for collection of fees have to be approved by the firm's management committee or by at least two 
		partners or officers?										 Yes   No
(e)	How many suits for collection of fees have been filed by the firm during the past two years?		     
(f)	Has the firm had a risk management seminar or audit conducted within the past 24 months by an 
independent third-party risk management specialist?								       	 	(  ) Yes   (  ) No

PRIOR INCIDENTS AND CLAIMS EXPERIENCE

	
22.	During the past five years, has any lawyer in the firm been refused admission to practice, disbarred or suspended from practice, or reprimanded, sanctioned or disciplined by any court or administrative agency?  	 Yes    No.   If yes, provide full details: 
	     
	     
     

23.	During the past ten years, has any professional liability claim been made against the firm or any predecessor in business or any of the past or present lawyers in the firm?  Yes   No.   If yes, provide full details on a separate sheet. The information should be presented clearly and in sufficient detail to enable the Old Republic Insurance Companies and Old Republic Professional Liability, Inc. to assess each claim. The information must include:
	(a)	the full name of the claimant(s);
	(b)	the exact date of claim (month/day/year);
 	(c)	the jurisdiction or location where the claim was made;
	(d)	the practice area(s) from which the claim arose;
	(e)	the individuals in the firm who are or were involved in the claim;
	(f)	the names of any other defendants;
	(g)	a description of the alleged acts, errors or omissions that caused the claim;
	(h)	the damages or other relief sought by the claimant(s);
	(i)	the name of the firm's insurance carrier and the date the claim was reported to them;
	(j)	the amounts paid in settlement of the claim or in satisfaction of any judgment (inclusive of any deductibles);
	(k)	the expenses incurred in defense of the claim (inclusive of any deductibles);
	(l)	the current status of the claim, including most recent developments.

 	NOTICE:		THIS APPLICATION WILL BE REJECTED IF THE FIRM FAILS TO PROVIDE ALL OF THE INFORMATION REQUESTED IN (a) THROUGH (l) FOR EACH CLAIM.

24.	(a)	After inquiry, does the firm or any lawyer in the firm know of any acts, errors, omissions or circumstances that could reasonably give rise to a professional liability claim against the firm or any predecessor in business or any of the past or present lawyers in the firm?   Yes    No.   If yes, provide full details: 
     
     
     
                                                                                                                                     
	(b)	Have all of the matters shown in (a) above been reported to the firm's current or former professional liability insurer?  
		 Yes    No.   If yes, give the name of the insurer and the date each matter was reported to them: 
     
      

	NOTICE:		THE POLICY BEING APPLIED FOR WILL NOT PROVIDE COVERAGE FOR ANY CLAIM ARISING OUT OF THE MATTERS REQUIRED TO BE LISTED IN 24. (a) AND 24. (b) ABOVE.

PRIOR INSURANCE

25.	Has the firm or any predecessor in business ever had an insurer cancel or refuse to renew their professional liability insurance?
	 Yes    No.   If yes, provide full details: NOT APPLICABLE IN MISSOURI
     
     
     

26.	Has the firm or any predecessor in business ever purchased an "extended reporting period" endorsement under a prior policy which extended the claims reporting period of that policy following its cancellation or non-renewal?   Yes    No.   If yes, provide full details: 
     
     

27.	Professional liability insurance written on a "claims made" basis has been carried by the firm since	     
	List the professional liability insurance carried by the firm for the past five years.  	                          (Mo/Day/Yr)
	
	Insurer	Limit of Liability	Deductible 	Premium	(Mo/Day/Yr)   (Mo/Day/Yr)
	
	        		$0.00    	$0.00 	$0.00	     	     
	        		$0.00    	$0.00 	$0.00	     	     
	        		$0.00    	$0.00 	$0.00	     	     
	        		$0.00    	$0.00 	$0.00	     	     
	        		$0.00    	$0.00 	$0.00	     	     

28.	Does the firm's current professional liability insurance contain an exclusion for claims relating to acts, errors or omissions committed prior to a specific date ("retroactive date")?   Yes    No.   If yes, indicate the retroactive date:        
									                                                               (Mo/Day/Yr)

29.	Desired Limit of Insurance:  $0.00 aggregate		Deductible:  $0.00 each claim.

THIS APPLICATION DOES NOT BIND THE FIRM, THE OLD REPUBLIC INSURANCE COMPANIES OR OLD REPUBLIC PROFESSIONAL LIABILITY, INC. TO COMPLETE THE INSURANCE; HOWEVER, THIS APPLICATION WILL BE THE BASIS OF THE CONTRACT IF A POLICY IS ISSUED, AND IT WILL BE ATTACHED TO AND MADE A PART OF THE POLICY.

THE UNDERSIGNED PARTNER OR OFFICER, ACTING ON BEHALF OF THE FIRM AND ALL PERSONS PROPOSED FOR THIS INSURANCE, REPRESENTS THAT ALL STATEMENTS RELATING TO THIS APPLICATION ARE TRUE.  THE UNDERSIGNED PARTNER OR OFFICER AGREES THAT IF ANY OF THE INFORMATION RELATING TO THIS APPLICATION CHANGES BETWEEN THE DATE OF THE APPLICATION AND THE EFFECTIVE DATE OF THE POLICY APPLIED FOR, THE UNDERSIGNED PARTNER OR OFFICER WILL IMMEDIATELY NOTIFY THE OLD REPUBLIC INSURANCE COMPANIES/OLD REPUBLIC PROFESSIONAL LIABILITY, INC. OF SUCH CHANGES AND THE OLD REPUBLIC INSURANCE COMPANIES/OLD REPUBLIC PROFESSIONAL LIABILITY, INC. SHALL HAVE THE RIGHT TO WITHDRAW OR MODIFY ANY OUTSTANDING QUOTATIONS AND/OR AUTHORIZATION OR AGREEMENT TO BIND THE INSURANCE.

THE UNDERSIGNED PARTNER OR OFFICER, ACTING ON BEHALF OF THE FIRM AND ALL PERSONS PROPOSED FOR THIS INSURANCE, AGREES THAT FEES, COSTS AND EXPENSES INCURRED IN THE INVESTIGATION AND DEFENSE OF CLAIMS SHALL BE APPLIED AGAINST THE DEDUCTIBLE (IF THE POLICY IS PRIMARY INSURANCE) AND SHALL REDUCE, AND MAY COMPLETELY EXHAUST, THE LIMIT OF LIABILITY OF THE POLICY.

Fraud Warning

(All States except: AL; AR; CO; DC; FL; HI; KS; KY; LA; ME; MD; NJ; OH; OK; OR; PA; TN; WA)

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.

Alabama – Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof.

Arkansas – Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Colorado – It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company.  Penalties may include imprisonment, fines, denial of insurance, and civil damages.  Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the department of regulatory agencies.

District of Columbia – WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines.  In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

Florida - Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. 

Hawaii – For your protection, Hawaii Law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.

Kansas – Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral, or telephonic communication or statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act.

Kentucky – Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance 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.

Louisiana – Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Maryland – Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

New Jersey – Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

Ohio – Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against any insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud, which is a crime.

Oklahoma – Any person who knowingly and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

Oregon – Any person who knowingly and with intent to defraud or solicit another to defraud an insurer: (1) by submitting an application containing a false statement as to any material fact, or (2) by filing a claim containing a false statement as to any material fact, may be violating state law.

Pennsylvania – 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 subjects such person to criminal and civil penalties.

Maine; Tennessee; Washington – It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company.  Penalties include imprisonment, fines, and denial of insurance benefits.

Date:      						Signed: 									                                                                                                                  

								Print Name: 	     			                                                                                                    

								Print Title: 	     	                                                                                                    
 										(Partner or Officer)

IOWA Applicants Only

The insurance for which this is an application 
was solicited by:

Print name: 	

Iowa license number: 	

Agency: 	

NEW HAMPSHIRE ONLY; FOR PRODUCER USE ONLY

Agency Name and Address:		

		
Agent’s New Hampshire
License I.D.#:		

Agent’s Signature:		
(stamped signature is not acceptable)

FLORIDA ONLY
FOR PRODUCER USE ONLY

Agency Name and Address:  		

		

Agent’s Florida License I.D.#:  		

Name of Agent:   		

Agent’s Signature:  		

Agent’s Name (printed):