Supplemental Application

For Adding a New Lawyer to 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*
Principal Business 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. New Lawyer Information
Requested Effective Date for coverage for New Lawyer*
Date Format: MM slash DD slash YYYY
Explain if the Date of Hire for any New Lawyer is Different from the Requested Effective Date for Coverage

Add New Lawyer

Lawyer Name	Bar Number & State	Admit Date	Date of Hire	Specialty Certified (Area)	Prior - Acts Date Requested
						Edit Delete
There are no New Lawyers.

III. Claim Experience and Bar Discipline
1. Does the New Lawyer or Firm have any knowledge of any error, omission or disagreement with any client which mightreasonably give rise to a claim or suit against him or her?*
- Yes
- No
Please Explain*
2. Has any claim(s) been made against Applicant or any current or former Lawyers arising from the performance of professional services during the past 10 years?*
- Yes
- No

Complete Supplemental Claims Sheet

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

3. Has New Lawyer withdrawn or had application declined for any professional liability policy or ever had any such policy non-renewed, cancelled, rescinded or coverage restricted?*
- Yes
- No
Please Explain*
4. Have any disciplinary proceedings been brought by the State Bar of California or any other state bar against the New Lawyer?*
- Yes
- No
Please Explain*
5. Has the New Lawyer been charged/convicted of any State or Federal offense?*
- Yes
- No
Please Explain*

IV. Other Interests
1. Does the New Lawyer own a controlling interest in any present or potential client of the Applicant or Policyholder?*
- Yes
- No
2. Is the New Lawyer currently engaged in any business venture with any person or entity to whom the Applicant or Policyholder also provides professional legal services?*
- Yes
- No
3. Is the New Lawyer a director, officer, trustee or employee of any organization/business entity (other than the Policyholder) including any bank, trust company, mortgage and loan association, building or savings and loan association, title guarantee or real estate company or corporation?*
- Yes
- No
IMPORTANT: Any Lawyer who becomes a stockholder in, partner of, employee of, or Of Counsel to the Named Insured during the policy period is covered solely with respect to acts on behalf of the Named Insured. A Lawyer shall be an Insured pursuant to sub-section 1.9(c) of the policy if, and only if, the Named Insured has given notice of the name of such Lawyer to the Company in writing within thirty (30) days after the date of such Lawyer becoming a stockholder in, partner of, employee of, or Of Counsel to the Named Insured, and such Lawyer has submitted appropriate underwriting information promptly upon request by the Company, and such information has been approved by the Company

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
New Lawyer Signature
Signature (New Lawyer)*
Print Name & Title*
Date*
Date Format: MM slash DD slash YYYY

Lawyers Professional Liability Insurance – Supplemental Application

I. General Information

Principal Business Address

II. New Lawyer Information

III. Claim Experience and Bar Discipline

IV. Other Interests

VI. Disclosure

Signature

New Lawyer Signature