Professional Liability Insurance for Recognized Organizations with DOJ Accredited Representatives

This is an application for a Claims Made Policy.

Name of Recognized Organization: *

Address: *

City: *

State: *

Zip Code: *

Phone Number: *

Email Address: *

Years in Business: *

Is your organization a 501(c)(3): *

Yes

Describe the operations of your organization with specific details of all services performed : *

List the name(s) of Accredited Representative(s): *

Client Case Management Information

Do you have a client case management system or similar tracking software? *

Yes

If not, provide details:

Who is responsible for entry assigned? *

Describe your client case management system with emphasis on cross-checking: *

Insurance History (must be completed in full)

List all Lawyers Professional Liability Insurance carried during the past five (5) years. If none, state "none" *

Lawyers Professional Liability Insurance:

	Policy Period (M/D/Y) (From/To)	Insurance Company	Limit	Premium
Policy Information	Policy Period (M/D/Y) (From/To)	Insurance Company	Limit	Premium
Policy Information	Policy Period (M/D/Y) (From/To)	Insurance Company	Limit	Premium
Policy Information	Policy Period (M/D/Y) (From/To)	Insurance Company	Limit	Premium
Policy Information	Policy Period (M/D/Y) (From/To)	Insurance Company	Limit	Premium

Please indicate Retroactive Date shown on the most recent policy (if shown as N/A please indicate): *

Claims History

Has any person in your organization been the subject to any past disciplinary or criminal proceedings? *

Yes

If yes, please describe:

Does any person to be insured have knowledge or information of any act, error, or omission which might reasonably be expected to give rise to a claim against them? *

Yes

If yes, please describe:

Has any claims or suits been made against an Accredited Representative? *

Yes

If yes, please describe:

Do you conduct any business activities outside of the USA where any OFAC Economic and Trade Sanctions or any other Regulations are currently in place? *

Yes

Name of Person Completing Application: *

Date: *

By clicking Submit it is understood that the insurance applied for will be issued on the acceptance of the application by Company. I/We hereby declare based upon my/our knowledge and upon reasonable investigation, the above statements are true and that I/We have not suppressed or misstated any material facts and this application shall be the basis of the contract with Lloyds of London.