Increased Limits Application

For Increasing Limits of an Existing Claims Made & Reported Policy
PLEASE COMPLETE FORM WITH FIRM INFORMATION AND RETURN WITH A SAMPLE OF YOUR LETTERHEAD
I. General Information
Policyholder Firm Name:*
Confirm Total Number of Lawyers*
Policy Number
Confirm Total Number of Staff*
Confirm Primary Address
Street Address*
City*
State*
Zipcode*
Email Address*
Does the Firm have a Satellite office(s)?*
- Yes
- No

Firm Satellite Offices Addresses

Street	City	State
			Edit Delete
There are no Addresses.

Confirm the Top 3 Areas of Practice

Areas of Practice

Area of Practice	% of Cases
		Edit Delete
There are no Areas of Practice.

II. Coverage Requested
Briefly describe the reason/need to Increase Limits. Attach any potential client or contract requirement.
File
Drop files here or

IV. Claim Experience and Bar Discipline
1. After inquiry of all lawyers in the firm, does Applicant have knowledge of any act, error, omission or disagreement which might reasonably give rise to a claim or suit?*
- Yes
- No
1. Explain*
2. Has the Firm or any lawyer at the Firm sued for fees during the past 5 years?*
- Yes
- No
Please Explain*
3. Has any lawyer at the Firm been charged/convicted of any State or Federal offense?*
- Yes
- No
Please Explain*
IMPORTANT: This Policy WILL NOT PROVIDE HIGHER LIMITS for any actual or potential CLAIMS KNOWN to any applicant/insured PRIOR TO THE INCREASE IN LIMITS OF THIS POLICY, including matters disclosed on this application.

V. Firm Management
1. Does the Firm use written letters on all matters for all clients for the following?
a. Engagement letter on new matters, outlining scope of representation & billing procedures*
- Yes
- No
b. Declination or non-engagement letter on new matter not undertaken*
- Yes
- No
c. Scope of service letter for new matters handled for existing clients*
- Yes
- No
d. Termination or disengagement letters at completion/termination of representation*
- Yes
- No
2. Does the Firm use a procedure to protect valuable and irreplaceable documents?*
- Yes
- No
3. Does the Firm use a system to cross reference clients to prevent potential conflicts of interest?*
- a. Manual conflict check
- b. Computerized conflict check
- c. Other
Other*
4. Does the Firm have a back-up attorney in the event of leave of absence?*
- Yes
- No
5. Does the Firm employ dual calendaring systems?*
- Yes
- No
Select applicable two*
- a. Lawyer calendar
- b. Matching staff calendar
- c. Computerized
- d. Other
Explain why the Firm doesn't employ dual calendaring systems.*
Other*
6. Is the calendar control system assigned to one staff person who has ultimate responsibility?*
- Yes
- No
7. How often are the calendars cross checked? Select one.*
- a. Daily
- b. Bi-Weekly
- c. Weekly
- d. Monthly
- e. Other
Other*
8. Does any lawyer at the Firm serve as a director, officer or trustee of a business other than the applicant law Firm?*
- Yes
- No

Firm Position

Position Held	Length of Service	Nature of Business	D&O Coverage Carried
				Edit Delete
There are no Firm Positions.

9. Has any lawyer at the Firm represented or served as director, officer, executive or committee member of any financial institution in any manner in last 5 years?*
- Yes
- No
Please Explain*
10. Does any lawyer at the Firm act in the capacity of accountant, insurance broker, real estate agent or entertainment agent? If yes, explain and provide information on any other E&O coverage.*
- Yes
- No
Please Explain*

VI. Disclosure
IMPORTANT NOTE The forgoing responses are true and complete. We understand 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. We hereby authorize the release and exchange of information involving underwriting and claims matters between the Company and our past and present carriers and we appoint the Company our attorney-in-fact for obtaining such information. We hereby authorize the State Bar of California to release information to the Company concerning membership, certifications and disciplinary proceedings. We agree 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.
Signature
Sample of Letterhead*
Signature (Owner, Partner, or Officer)*
Print Name & Title*
Date*
Date Format: MM slash DD slash YYYY

Lawyers Professional Liability Insurance – Increased Limits Application

I. General Information

Confirm Primary Address

II. Coverage Requested

III. Limits and Deductible

IV. Claim Experience and Bar Discipline

V. Firm Management

VI. Disclosure

Signature