Entertainment Law Program Application

Office: Designate at which office Lawyer(s) primarly work - P = Principal Office; S= Satellite office

Status: FT Full Time or PT = Part Time (working 20 hours or less per week)

Relationship: E = Employee/Member of firm; DR = Discovery Reference; IC = Independent Contractor; IHC = In House Counsel; OC = Of Counsel; PD = Private Public Defender; PROS = Private Prosecutor

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. However, prior acts coverage is available upon request and approval with submission of proof of current coverage.

Complete the table below based on the Average Caseload during the last 3 years

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.

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.