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Wesco Insurance Company	APPLICATION FOR LAWYERS	Administered by:
800 Superior Ave. E	APPLICATION FOR LAWYERS	<Insert Managing Agency name here>
21st Floor	PROFESSIONAL LIABILITY	<Insert Managing Agency address here>
Cleveland, OH 44114	INSURANCE	<Insert Managing Agency address here>
Cleveland, OH 44114	(Claims Made and Reported Policy)
	(Claims Made and Reported Policy)

THIS IS AN APPLICATION FOR A CLAIMS MADE AND REPORTED INSURANCE POLICY. IT IS IMPORTANT THAT YOU REPORT ANY KNOWN FACTS OR CIRCUMSTANCES THAT COULD REASONABLY BE EXPECTED TO RESULT IN A CLAIM TO YOUR CURRENT INSURER OR PURCHASE AN EXTENDED REPORTING PERIOD ENDORSEMENT IN ORDER TO PRESERVE COVERAGE FOR SUCH INCIDENTS.

Full Name of

Applicant Firm:

Address 1:

Contact:

Address 2:			City:	State:	Zip Code:

County:			Phone:		Fax:

E-mail:				Date Firm Established:

No. Lawyers in Firm:		No. Support Staff:

Do you have other office locations?	Yes	No	If yes, how	Please provide a list showing each location
			many?	and the number of attorneys at each location

1.Requested Effective Date:

2.	a. Current Limits:	b. Limits desired this year:
	c. Current Deductible:	d. Deductibles desired this year:
	e. Optional coverages you are requesting:

First Dollar Defense:

Aggregate Deductible:

f.Retroactive Date Requested:

Claim Expense Outside Limits:

a. Is the firm currently insured for professional liability?

Yes

Please provide a copy of your current policy declarations including retroactive date as evidence of current coverage.

b. Does your current policy have any type of endorsements that exclude or modify coverage?

Yes

If yes, please provide a copy of each such endorsement.

List the names of all predecessor firms of the applicant firm.

Name only those firms where the applicant is a

majority successor to the predecessor firm’s assets and liabilities.

Name of Predecessor Firm

Date Established

Number of Lawyers

Do you share any of the following with other attorneys or law

firms?

Office Space:

Yes

Letterhead:

Yes

Cases:

Yes

If yes, list all such lawyers on firm

letterhead and describe their

relationship to the firm. If the firm shares office

space, a complete Office Sharing Supplement must be provided.

a. In the last 12 months, how many attorneys have left your firm?

b. Joined the firm?

c. How many attorneys does the firm plan to add during the next 12 months?

d. In the last 12 months, how many non lawyer employees have left your firm?

Has any professional liability insurance for the applicant, or any member of the applicant firm ever been

Yes

declined or cancelled, refused to be renewed or accepted only on special terms?

If yes, please provide a detailed narrative in the space provided on page 2 or on firm letterhead.

Please identify your legal professional liability insurance for the past five years.

Company

Policy Period

Limits

Deductible

Premium

# of Attorneys

WIC-LPL-APP-01 (1016)

Page 1 of 8

9.	Does any client or group of related clients make up 10% or more of the firm’s gross receipts?	Yes	No
	If yes, please list all clients and the percentage of the firm’s gross receipts in the space provided below.
10.	Does your firm use any attorneys not listed on this application to provide legal services for the firm?	Yes	No
	If yes, list all such lawyers in the space provided below and describe their relationship to the firm.
11.	Is any lawyer listed on the application an officer, director, shareholder, member or exercise fiduciary	Yes	No
	control over an entity other than the applicant firm?
	If yes, a complete Outside Interest Supplement must be provided.
12.	Is any lawyer listed on the application an employee of an entity other than the applicant firm?	Yes	No
	If yes, please explain in the space provided below or on firm letterhead.
13.	Has any member of the firm provided legal services involving publicly traded securities or securities	Yes	No
	that are not exempt from registration?
	If yes, please explain in the space provided below or on firm letterhead.
14.	Has any member of the firm been involved in class action or mass tort litigation?	Yes	No
	If yes, please explain in the space provided below or on firm letterhead.
15.	Does any member of the firm provide services to, or sit on the board of directors of, a	Yes	No
	financial institution?
	If yes, a complete Financial Institution Supplement must be provided.
16.	Is any firm member aware of any incident, facts, circumstances, acts or omissions that	Yes	No
	could result in a professional liability claim against the firm or predecessor firm or against any
	current or former firm member while affiliated with the firm or predecessor firm?
	If yes, a complete Claim Supplement form must be provided for each incident.
17.	Has any member of the firm been the subject of any reprimand or disciplinary action or	Yes	No
	refused admission to the bar or any bar association, court or administrative agency?
	If yes, explain in detail in the space provided below.
18.	a. In the last 5 years, has any professional liability claim been made or suit brought against	Yes	No
	the firm or predecessor firm or any member of the firm or predecessor firm?
	If yes, how many claims:
	b. Has any member of the firm ever had a claim?	Yes	No
	If yes, a complete Claim Supplement form must be provided for each claim or suit within the past 5 years.

	SPACE PROVIDED FOR ADDITIONAL INFORMATION






















WIC-LPL-APP-01 (1016)		Page 2 of 8

19.Complete the following table based upon either your gross revenue or billable hours for each category. The total must equal 100%

This Practice Profile is based on gross revenue or billable hours.

PRACTICE PROFILE

Area of Practice	Percentage	Area of Practice	Percentage
Admiralty (AM)	Plaintiff %:	Health Care (HC)	Plaintiff %:
	Defense %:		Defense %:
	Other %:		Other %:
Antitrust (AT)	Plaintiff %:	Insurance Defense (ID)	Coverage%:
	Defense %:		Defense %:
	Other %:		Other %:
Appellate (AP)	Plaintiff %:	Intellectual Property * (IP)	Patent %:
	Defense %:		Trademark %:
	Other %:		Litigation%:
Arbitration, Mediation (ADR)	%:	Labor & Employment (LE)	Management %:
Bankruptcy * (BC)	Debtor%:		Union/Labor%:
	Trustee%:		Other %:
Business Formation &	Form/Alt %:	Municipal Law (ML)	Defense %:
Alteration, Merger/Acquisition *	Merge/Ac%:		Financial Advice:
(CF)	Other %:		Other %:
Business Transactions -	Public Corp %:	Natural Resources, Oil & Gas (NR)	Plaintiff %:
Corporate & Commercial * (CF)	Private %:		Defense %:
	Other %:		Other %:
Civil Rights/Discrimination (CR)	Plaintiff %:	Personal Injury Legal Malpractice*	Plaintiff %:
	Defense %:	(PI)	Defense %:
	Other %:		Other %:
Collections * (CB)	Creditor %:	Personal Injury Medical	Plaintiff %:
	Debtor %:	Malpractice* (PI)	Defense %:
Commercial Litigation (GL)	Plaintiff %:		Other %:
	Defense %:	Personal Injury Mass Tort,	Plaintiff %:
	Other %:	Class Action * (PI)	Defense %:
Construction Law (CL)	Plaintiff %:		Other %:
	Defense%:	Personal Injury Products Liability*	Plaintiff %:
	Transaction %:	(PI)	Defense %:
Criminal Defense (CD)	%:		Other %:
Employee Benefits (EB)	%:	Personal Injury * (PI)	Plaintiff%:
Entertainment/Agency/	Management %:		Defense %:
/Sports Agency *(EN)	Other %:		Other %:
Environmental * (ER)	Plaintiff %:	Real Estate * (RE)	Commercial %:
	Defense %:		Residential%:
	Other %:	Securities * (SE)	Public Offering%:
Estate, Probate, Trust * (ES) (1)	Est. Planning %:		Corp. Bonds %:
	Trust Admin. %:		Private Placemt:
	Other %:		Other %:
Family Law (FL) (2)	Adoption %:	Tax, Tax Opinions (TX)	Personal %:
	Divorce %:		Corporate %:
	Other %:		Other %:
Financial Institutions * (FI)	%:	Workers Compensation/Social	Plaintiff %:
General Civil Litigation (GL)	Plaintiff %:	Security (WC)	Defense %:
	Defense %:		Other %:
	Other %:	Other (OT) (Describe):	%:
Immigration (IM)	%:		%:

* Indicates that completion of the corresponding Supplement is required.

(1)Estate/Trust/Probate. In the last 24 months, please indicate the following:

Average asset value of estates handled:		Highest asset value of estates handled:
Is any firm member a trustee of any client estate?	Yes	No If yes, please complete an Outside Interest Supplement

(2) Family Law. In the last 24 months, please indicate the following:

Average value of property settlement handled:

Does any firm member provide any of the following services?

Highest value of property settlement handled:

Surrogacy contracts	Ovum or sperm donation contracts	Embryo donation agreements
WIC-LPL-APP-01 (1016)		Page 3 of 8

20.

a.Please complete the Firm Profile below for each attorney associated with your firm. Please attach an additional sheet if more space is needed.

FIRM PROFILE

Attorney Name

Position

P, A,

OC, I

Hire

Date

Date First Admitted

States

Admitted

Ave.

Hours/

Week

Primary - P

Secondary - S

Areas of Practice

Cover for work prior to date of hire by firm? Y/N

P = Partner/Owner/Member A = Associate/Employee OC = Of Counsel I = Independent Contractor

21.	If you are a sole practitioner, who handles your cases in the event of your incapacitation or vacation? (Please
	Note: If a policy is issued in reliance upon this application, it shall not apply to the attorney noted below):
	Name of backup attorney:
22.	Total firm billings last fiscal year:			Current fiscal year billings:

23.	Does your firm accept any form of compensation other than legal fees?							Yes	No
	If yes, please provide an explanation in the space provided on page 2 or on firm letterhead.

24.	Does your firm have a system for detecting and avoiding conflicts of interest?							Yes	No
	If yes, check all that apply:
	Index	Computer	Conflict Committee		Oral/Memory		Other:	Describe:

25.	a. Does or has any member of the firm engaged in a business venture with a client?							Yes	No

	b. Does or has any firm member introduced clients to one another for investment purposes?							Yes	No

	c. Does the firm ever represent adverse but friendly parties in the same matter?							Yes	No

	If yes to 25. a, b, or c, please provide an explanation in the space provided on page 2 or on firm letterhead.

26.	Please indicate which of the following the firm uses to manage its docket and scheduling demands:
	Computer	Docket Clerk/Administrator		Individual Diaries		Daily or		Weekly firm-wide circulation of
	master calendar	Other: Describe:

27.	If the firm uses a computerized system to manage its docket and scheduling demands, please indicate below which of the
	following describes that system:				Name of software:
	Updated daily	Centralized/Firm-wide		All branch offices integrated			Monitored by multiple individuals
	Tracks statutes of limitations		Data backed up/stored offsite			Other: Describe:
WIC-LPL-APP-01 (1016)									Page 4 of 8

28.	Does the firm routinely use:

	Engagement letters/Fee Agreements:	Yes	No	Declination of Representation Letters:		Yes	No

	Termination of Services Letters:	Yes	No	Regular File Status Updates:		Yes	No

29.	Have any suits for fees been filed against clients in the last five			years?	Yes	No
	If yes, please complete the Fee Suits Supplement.

30.	Describe the firm’s risk management activities:

	a. Does the firm have a formal procedures manual?				Yes	No

	b. Are all employees trained regarding firm policies and procedures?				Yes	No

	c. Are new attorneys supervised by a more senior attorney?				Yes	No

	d. Are all cases brought in by new attorneys from prior firms reviewed by at least one senior
	partner or officer of the firm for potential conflicts of interest?				Yes	No

	d. Is support personnel work reviewed by an attorney prior to release to the client?				Yes	No

	e. Are all new matters reviewed prior to acceptance by firm management?				Yes	No

	f. Does firm management regularly review all ongoing matters?				Yes	No

WIC-LPL-APP-01 (1016)

Page 5 of 8

Fraud Warning

Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which may be a crime and may subject the person to criminal penalties.

ALABAMA, ARKANSAS, LOUISIANA, NEW JERSEY, NEW MEXICO, RHODE ISLAND, VIRGINIA and WEST VIRGINIA: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an Application for insurance is guilty of a crime. In Alabama, Arkansas, Louisiana, Rhode Island and West Virginia that person may be subject to fines, imprisonment or both. In New Mexico, that person may be subject to civil fines and criminal penalties. In Virginia, penalties may include imprisonment, fines and denial of insurance benefits.

COLORADO: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

DISTRICT OF COLUMBIA, KENTUCKY and PENNSYLVANIA: Any person who knowingly and with intent to defraud any insurance company or other person files an Application for insurance or statement of claim containing materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime. In District of Columbia, penalties include imprisonment and/or fines. In addition, the Insurer may deny insurance benefits if the Applicant provides false information materially related to a claim. In Pennsylvania, the person may also be subject to criminal and civil penalties.

FLORIDA and OKLAHOMA: Any person who knowingly and with intent to injure, defraud or deceive the Insurer, files a statement of claim or an Application containing any false, incomplete or misleading information is guilty of a felony. In Florida it is a felony to the third degree.

KANSAS: An act committed by any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an Insurer, purported Insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for personal or commercial insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto is considered a crime.

MAINE: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or denial of insurance benefits.

MARYLAND: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or knowingly or willfully presents false information in an Application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

OHIO: Any person who, with intent to defraud or knowing that he is facilitating a fraud against the Insurer, submits an Application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

OREGON: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance may be guilty of a crime and may be subject to fines and confinement in prison.

TENNESSEE and WASHINGTON: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines and/or denial of insurance benefits.

WIC-LPL-APP-01 (1016)

Page 6 of 8

APPLICANT’S AUTHORIZATION AND CERTIFICATION

The undersigned is an authorized representative of the prospective Named Insured, and acknowledges that the information provided with the application, including all supplements, attachments and replies to underwriter inquiries, and applications from other insurance companies which have been submitted to the Company and made a part of this application:

1.Will be relied upon by the Company in determining the acceptability of the Applicant and the premium amount to be charged;

2.Are true, accurate and complete; and

3.Will be incorporated into the policy, if issued.

The applicant firm and all members of the firm understand that this is an application for insurance, and shall not bind the Company to the issuance of insurance, nor shall it bind the firm to the acceptance of a policy.

THE UNDERSIGNED ON BEHALF OF THE APPLICANT FIRM AND ALL MEMBERS OF THE FIRM CERTIFIES THAT THE ABOVE APPLICATION HAS BEEN READ AND THAT ALL STATEMENTS MADE IN THIS APPLICATION ARE TRUE, MATERIAL AND COMPLETE. THE UNDERSIGNED UNDERSTANDS THAT: (1) IF THE POLICY IS ISSUED, THIS IS DONE BY THE COMPANY IN RELIANCE UPON THESE REPRESENTATIONS; AND (2) ANY COVERAGE OBTAINED BY FRAUD, MATERIAL MISREPRESENTATION OR OMISSION IS VOID.

The following number of Supplemental Claim forms are enclosed with this application:

Signature of Officer or Partner of Firm

Print Name

Title

Date

AGENCY:

ADDRESS:

PHONE:

FAX:

WIC-LPL-APP-01 (1016)

Page 7 of 8

Wesco Insurance Company

800 Superior Ave. E

21st Floor

Cleveland, OH 44114

CLAIM SUPPLEMENT

1.	Full name of Applicant Firm:
2.	Full name(s) of firm member(s) involved in claim:
3.	Other defendants:
4.	Name of potential/actual claimant(s):
5.	Check whether:	Incident		Claim		Lawsuit		Disciplinary Action
6.	a. Date of alleged act, error, or omission:
	b. Date reported to insurer:
	c. Name of insurance carrier responding to this claim:
7.	Present status of claim (check one and include any deductible amount in figures provided):
	Closed				Open
	Total loss paid (including deductible):		$		Claimant's settlement demand:			$
	Total expense paid (including deductible):		$		Defendant's offer for settlement:			$
	Court judgment			Insurer's claim reserve:		$
	Out-of-court settlement			Expense reserve:		$
	Dismissed			Expenses paid to date:		$
	Arbitration award	Currently In Suit		Incident/Report Only (No reserve established, no expenses to date)
8.	a. Alleged act or omission upon which claim or incident is based:
	b. Description of events leading to claim or incident:
	c. Current status:
	d. What steps have been taken to prevent a similar loss in the future?
	e. Does this claim or incident arise from an action to collect fees?				Yes		No

I represent that the statements above are true and complete to the best of my knowledge, that I have not suppressed or misstated any facts and I understand that this supplement becomes part of my application.

Signature of Officer or Partner of Firm	Title	Date

Print Name of Officer or Partner
WIC-LPL-APP-01 (1016)		Page 8 of 8

Question	Answer
Form Name	Form Wic Lpl App 01
Form Length	8 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	2 min
Other names	wic lpl app, wic lawyers company form, wic lawyers professional form, app01 company get

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