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Direct Line: 818-565-5512
Hot Line: 800-252-2045
Cyber Inquiries: 818-382-2030
After Hours Cyber: 877-316-1627
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.
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:
Please choose from the following options: Yes/No
Please choose one of the following:Yes/No
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.
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.