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

RENEWAL APPLICATION
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. 

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

	Contact Person:	     

	Telephone No: 	          	Email:       
		
2.	Since completion of your last application, has the firm:
	(a)	Opened or closed any offices?		 Yes   No
(b)	Merged or consolidated with any other law firm? 		 Yes   No
(c)	Changed its name or business structure? 		 Yes   No
If “Yes,” please provide full details on a separate sheet.

3.	Please indicate the current number of lawyers and staff (include all offices):

	Lawyer Profile	Number							Staff Profile			Number
Partners or Shareholders	     							Investigators			     
	Employed Lawyers	     							Paralegals			     	
	Of Counsel Lawyers	     							Clerical				     	
	Contract Lawyers	     							Other 				     
	Total	     							Total				     		

Please provide a current list of lawyers which includes at least the following information for each person: (a) full name, (b) his or her status with the firm, (c) number of years in private practice and (d) date he or she joined the firm.

4.	Please provide the following information concerning the firm's practice areas and the percent of total income which each area represents:

		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.

5.	Since completion of your last application, has any lawyer provided legal services or advice in
	connection with the offering, sale or distribution of any debt or equity securities?	 Yes    No
If “Yes,” please provide the following information on a separate sheet: (a) date of offering, (b) name 
of issuer, (c) business activity of issuer, (d) form of security, (e) dollar size of offering, (f) name of 
underwriter, (g) name of accountant and (h) client represented.

6.	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:	     

7.	Please provide the following information for the firm’s last two fiscal years:

	Fiscal Year Ending:  	     	     
Total Billable Hours: 	     	     
Gross Income:	$0.00	$0.00
	Net Income:	$0.00	$0.00

8.	Do you anticipate a material increase or decrease in the firm’s total billable hours, gross income 
	or net income for the current fiscal year? 		 Yes    No
If “Yes," please provide the reason(s) for any material increase or decrease on a separate sheet.

9.	Since completion of your last application, has the firm filed any suits against clients for the 
	collection of fees?		 Yes    No
If “Yes,” please provide the following information on a separate sheet: (a) name of client, 
(b) date(s) of service, (c) a description of the legal services rendered, (d) total amount overdue 
and (e) current status of the suit.

10.  Since completion of your last application, has the firm changed any of the following systems or 
	procedures:
	(a)	Client Intake Procedures?		 Yes    No
	(b)	Conflict of Interest System?		 Yes    No
	(c)	Docket Control/Calendar System?..		 Yes    No
	(d)	Use of Engagement Letters, Declination Letters and Disengagement Letters?		 Yes    No
If “Yes,” please provide full details on a separate sheet.

11.	Since completion of your last application, has any lawyer become licensed or begun operating
	in any professional capacity other than as a lawyer?	 	 Yes    No
If “Yes,” please provide the name of the lawyer and describe the capacity in which he or she acts 
(e.g. accountant, real estate agent, title agent, investment adviser, claims adjuster, etc.) on a 
separate sheet.

12.	Since the completion of your last application, has any lawyer in the firm:
(a)	Become a director, officer, partner, trustee or employee of any enterprise which is also a 
		client of the firm?		 Yes    No
	(b)	Acquired a financial interest in any client of the firm?	 	 Yes    No
(c)	Become an executor, administrator, conservator, guardian or trustee, or begun acting in any 
		similar fiduciary capacity on behalf of any client?		 Yes    No
If “Yes,” please provide the following information on a separate sheet: (a) name of lawyer, (b) name 
of client, (c) nature of client’s activities, (d) capacity in which the lawyer acts and (e) percent of equity 
owned by the lawyer.

13.	Since completion of your last application, has any lawyer in the firm:
(a)	been refused admission to practice, disbarred or suspended from practice, reprimanded, 
		sanctioned or disciplined either publicly or privately by any court or administrative agency?			 Yes    No
	(b)	been charged or convicted of a federal or state offense?			 Yes    No
	If “Yes,” please provide full details on a separate sheet. 

14.	Since completion of your last application: 
(a)	Has there been a change in the status of any claim or previously reported incident that could give 
		rise to a claim (whether reported to Old Republic Insurance Company or any other insurer)? 		 Yes    No 

	(b)	Has any claim been made against the firm or any predecessor in business or any of the past
	or present lawyers in the firm or any predecessor in business which has not been reported 
		to the Old Republic Insurance Company?		 Yes    No
If “Yes," please provide full details on a separate sheet.

15.	After inquiry, is any lawyer in the firm or other person for whom insurance is requested aware of 
any act, error, omission or circumstance which could reasonably give rise to a claim being made 
against the firm or any predecessor in business or any of the past or present lawyers in the firm 
	or any predecessor in business?		 Yes    No
If “Yes," please provide full details on a separate sheet.

16.	Please specify the limits of liability and deductible that you desire for renewal:
Limits of Liability (each claim/aggregate):	$0.00
	Deductible (each claim):	$0.00

Representations

Completion of this application does not obligate the firm to purchase any insurance nor does review of this application obligate Old Republic Professional Liability, Inc. to offer any insurance on behalf of the Old Republic Insurance Company. If insurance is effected, however, the application will be basis of the policy and a copy of the application will be attached to and made a part of the policy.

The undersigned partner or shareholder, acting on behalf of the firm and all persons for whom insurance is requested, represents that the statements in this application and accompanying documents are true, accurate and complete, and agrees that if any of the information changes between the date of the application and the inception date of the proposed policy, he/she shall immediately report such changes to Old Republic Professional Liability, Inc. who shall then have the right to withdraw or change any outstanding quotation or agreement to bind coverage on behalf of the Old Republic Insurance Company.

The undersigned partner or shareholder of the firm understands and accepts that any policy issued on behalf of the Old Republic Insurance Company will provide coverage on a claims made and reported basis and that all legal fees and expenses incurred in the investigation and defense of any claim will be applied against the deductible and will 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):