Low Income Lawyer Program - Lawyers Mutual Insurance Company

LILP Application

Step 1 of 3 - I. General Information II. Firm - Area of Practice III. Limits and Deductible

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LAWYERS PROFESSIONAL LIABILITY INSURANCE LOW INCOME LAWYER PROGRAM (LILP) APPLICATION Claims Made and Reported Policy
Please complete this form to the best of your knowledge and return with a sample of the Firm's Letterhead. Page three of this application will provide a file upload option.
* Asterisk denotes required field
I. General Information:
1a. Full Name of Applicant Lawyer: **
Prefix First Middle Last Suffix
Law School:
Degree Date obtained:
Date Format: MM slash DD slash YYYY
State Bar Number: **
Please include prefix zeros if your SBN does not equate to 8 numerical characters. e.g. 123456, 00123456
Date of Admission:
Date Format: MM slash DD slash YYYY
Primary Address: **
Street Address Address Line 2 City State ZIP Code
Primary Contact Number: **
Primary Fax Number:
Primary Contact Email: **
Website Address:
Date the Firm was Established:
Date Format: MM slash DD slash YYYY
Effective Date Requested:**
Date Format: MM slash DD slash YYYY
Applicant Lawyers is an:*
- Individual
- Corporation
Is the Applicant Lawyer a Solo Practitioner?**
- Yes
- No
If No, please explain:
If No, please explain:**
Note: “Solo practitioner” means that you or your professional corporation do not employ any other lawyers, and do not have a partner, a professional association or any similar arrangements. You can act as an “Of Counsel” or act as an Independent Contractor for another lawyer or law firm (subject to underwriting criteria).
II. Firm - Area of Practice:
Please indicate the top 3 Areas of Law and the percentage practiced based upon Applicant Lawyer’s caseload for the last three years or if less than three years, the amount of time that Applicant Lawyer has most recently been a solo practitioner. If this is a new practice, indicate anticipated Areas and percentages.
1. Area %: (e.g. 75% Marriage) 2. Area %: (e.g. 15% Intellectual) 3. Area %: (e.g. 10 % Trademarks)
Note: If ANY percentage of your practice does or will include class action, copyrights, patents, trademarks, intellectual property, entertainment, environmental, investment counseling/money management, personal injury, municipal land, public utilities, real property, securities, tax or estate planning, then (on a separate sheet) please specify the Area of Law, percentage, type of client and describe the legal services to be performed
If applicable, (virtual sheet): please specify the Area of Law, Percentage, type of client, and a brief description of the legal services to be performed:
IMPORTANT: This is an application for a Claims-Made and Reported Policy. The Policy issued by Lawyers’ Mutual Insurance Company EXCLUDES coverage for your prior acts. This means that the Company will not defend or indemnify you for any claim arising out of an act, error or omission which occurred prior to the Policy effective date.
III. Limits and Deductible:
Upon approval of this LILP Application, the Limits of Liability for the LILP policy will be $100,000 each claim/$100,000 annual aggregate with a $250 per claim deductible. No additional limit or deductible options will be available.

IV. Claim Experience and Professional Standing:
Please choose from the following options: Yes/No
1. Has the Applicant Lawyer ever withdrawn or had declined an application for any professional liability policy, or ever had any such policy non-renewed, cancelled, rescinded or had coverage restricted?
Please choose from the following options: Yes/No
2. Does the Applicant Lawyer have knowledge of or reason to suspect any act, error, omission or any disagreement with any former or current client, employer or third party or dissatisfaction with services rendered or fees charged, which might reasonably give rise to a claim or suit against the Applicant Lawyer?
Please choose from the following options: Yes/No
3. Has the Applicant Lawyer ever had any claim made against him or her alleging any liability arising from the performance of professional services? **

Please complete ONE FORM for EACH CLAIM OR INCIDENT and answer completely

Firm Name	Claim Number	Claimant(s) Name
			Edit Delete
There are no Entries.

Please choose from the following options: Yes/No
4. Has the Applicant Lawyer ever had or defended a claim against him or her and not reported it to an insurance carrier?
Please choose from the following options: Yes/No
5. Has the Applicant Lawyer sued for fees during the past 3 years?
Please choose from the following options: Yes/No
6. Has any disciplinary proceeding (including but not limited to reprimand, reproval,probation, suspension or disbarment) ever been brought by the State Bar of California, or any other State Bar, against the Applicant Lawyer?
Please choose one of the following:Yes/No
7. Has the Applicant Lawyer ever been refused admission to practice before any court or administrative agency?
Please choose one of the following:Yes/No
8. Has the Applicant Lawyer ever been charged or convicted of any state or federal offense?
IMPORTANT: This Policy WILL NOT PROVIDE COVERAGE for any actual or potential CLAIMS KNOWN to any applicant/insured PRIOR TO THE INCEPTION OF THIS POLICY, including matters disclosed on this application. Any such claims should be reported to your current carrier prior to expiration of your current Policy.
V. Income and Insurance:
9. What was the Applicant Lawyer’s gross revenue from legal services for each of the last three years?*
Year 1) Year 2) Year 3)
Please choose from the following options: Yes/No
10. Has the Applicant Lawyer been covered by professional responsibility insurance for his/her legal services as a solo practitioner in the past one year? If yes, prior acts coverage will not be offered to new applicants.
VI. Firm Management:
11. Does Applicant Lawyer have a system for cross-referencing his/her own client list in order to prevent potential conflicts of interest? Explain:
12. Check which of the following calendaring systems Applicant Lawyer utilizes.
To select multiple choices, simply hold the Ctrl key on your keyboard while selecting a through c.
If Other (explain):
13. Describe how the calendars checked in Question 12.a and Applicant Lawyer’s internal office procedures are coordinated to notify him/her of scheduled matters on these calendars

VII. Disclosure:
IMPORTANT NOTE
The forgoing responses are true and complete. Applicant understands that the Company will rely upon the accuracy of this application and that the Company retains the right to rescind any Policy which is issued based upon an application containing false or incomplete information. Applicant hereby authorizes the release and exchange of information involving underwriting and claims matters between the Company and our past and present carriers and appoints the Company our attorney-in-fact for obtaining such information. Applicant hereby authorizes the State Bar of California to release information to the Company concerning membership, certifications and disciplinary proceedings. Applicant agrees any person or organization furnishing information to the Company pursuant to this authorization will not be liable for furnishing such information, even if the information is inaccurate or untrue.

THIS APPLICATION WILL BE CONSIDERED ONLY IF ALL QUESTIONS ARE ANSWERED, LETTERHEAD IS ATTACHED, AND THE APPLICATION IS SIGNED AND DATED BY AN OWNER, PARTNER OR OFFICER OF THE APPLICANT FIRM. APPLICANT MUST REPORT ANY CHANGES IN THESE ANSWERS OF WHICH IT BECOMES AWARE AFTER SIGNING THIS APPLICATION BUT BEFORE THE EFFECTIVE DATE OF THE POLICY. IF APPLICANT BECOMES AWARE OF ANY ACTUAL OR POTENTIAL CLAIM AFTER SIGNING THIS APPLICATION AND BEFORE THE EFFECTIVE DATE OF THE POLICY, SUCH ACTUAL OR POTENTIAL CLAIM WILL NOT BE COVERED UNDER THIS POLICY.
VIII. Warranty and Signature:
YOU UNDERSTAND AND AGREE THAT, BY SIGNING THIS APPLICATION, YOU WARRANT THAT ALL ANSWERS HEREIN, INCLUDING THOSE IN SECTION V REGARDING INCOME FROM PROFESSIONAL SERVICES, ARE TRUE AND CORRECT, AND YOU ACKNOWLEDGE THAT THE PROPOSED INSURANCE, IF ISSUED, WILL BE ISSUED IN RELIANCE ON THIS WARRANTY.
Applicant' Signature**
Enter Name and Title:**
Date**
Date Format: MM slash DD slash YYYY
Preferred Method of Contact:**
(please select one)
Please attach any file(s) to be considered with your online application: (e.g. your sample of the Firm’s Letterhead)**
Drop files here or

Accepted file types: docx, pdf, xlsx.
Please submit your sample of the Firm’s Letterhead
For clarification, please CONTACT our UNDERWRITERS at: 1-800-252-2045
Name
This field is for validation purposes and should be left unchanged.

1. Area %: (e.g. 75% Marriage)	2. Area %: (e.g. 15% Intellectual)	3. Area %: (e.g. 10 % Trademarks)

Low Income Lawyer Program Application

LILP Application

Step 1 of 3 - I. General Information II. Firm - Area of Practice III. Limits and Deductible

I. General Information:

II. Firm - Area of Practice:

IV. Claim Experience and Professional Standing:

V. Income and Insurance:

VI. Firm Management:

VII. Disclosure:

VIII. Warranty and Signature: