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

BROKER APPOINTMENT APPLICATION
LAWYERS PROFESSIONAL LIABILITY [LPL]

1. 	Name of Applicant Organization:      

2.	Address:	     
     
     

3. 	Telephone:       	Fax:       	Web site:      

4.	Number of years in business:       	Wholesaler   	Retailer  	Both 
 
5.  	Ownership of Organization         	

6. 	Names of all staff responsible for handling LPL business:
     	     	
     		     	
     		     	
	
8. 	Total annual LPL premium volume:    	$      

9. 	Three largest LPL markets:	     
					     
					     

10.	Has the applicant organization at any time during the past three years held underwriting authority for LPL, including any current authority?  Yes ___ No ___  If Yes,

	Carrier Name	     Period of Authority    	Limit         	Annual Premium Volume
	     	     	     	     
	     	      	     	     	
11.	Which other states will business come from, apart from applicant’s state of domicile?
	     	

12.	Expected annual premium volume with Old Republic Professional Liability, Inc.?   $     

Name and Title of person completing this application:       	
		                                                           
Signature:  __________________________________        Date:	     	
•	Approval of the applicant organization is subject to ongoing review by Old Republic Professional and may be withdrawn at any time.
•	This application is valid only for Old Republic Professional, and no other entity of Old Republic International Group.
•	This in no way constitutes a formal agency appointment by any member of the Old Republic International Group.
•	If the applicant organization has more than one office, each office must submit its own application.