Application & Questionnaire

Qualifying Questionnaire
To be eligible for the premium options shown below, the responses to statements 1 through 6 must all be “True”.
The applicant is a solo professional and does not have any employees.
- True
- False
The applicant provides services as a licensed legal paraprofessional acting within the areas and scope of practice in accordance with state law.
- True
- False
The applicant does not provide services as a lawyer.
- True
- False
The applicant’s total gross revenues are not expected to exceed $100,000 during the next 12 months.
- True
- False
The applicant is not aware of any professional liability claim or any acts, errors, omission or personal injuries which might reasonably be expected to be the basis of a claim made against them within the past 5 years.
- True
- False
The applicant, in the past five years, has not had their license revoked, or been subject to a disciplinary action, investigation, inquiry or fine by any licensing board, regulatory agency or professional association.
- True
- False
SELECT YOUR DESIRED PREMIUM OPTION AND REMIT WITH YOUR APPLICATION
- $250,000 / $250,000
- $500,000 / $500,000
- $1,000,000 / $1,000,000
Deductible per claim: $1,000

Annual Premium: $525

Total Premium*: $593.40
*includes fees/taxes
Deductible per claim: $1,000

Annual Premium: $693

Total Premium*: $766.78
*includes fees/taxes
Deductible per claim: $1,000

Annual Premium: $924

Total Premium*: $1005.17
*includes fees/taxes
The terms and conditions given above are subject to change or withdrawal based upon review of the completed application. If this policy is issued, the form used will be Nationwide’s Scottsdale Indemnity Company, Form No MRI-PT- P-7 (04-21). Scottsdale Indemnity Company is a Non-Admitted carrier, AM Best rating A+. I hereby authorize Vanguard Specialty to bind coverage with the selected Insurer above, at the terms and conditions as outlined in the applicable sections of this quote.

Applicant Information
Name*
First Middle Last
Address
Street Address Address Line 2 City State ZIP Code
Email*
Phone*
Does the Applicant render professional services through a legal entity?
- Yes
- No
If “Yes,” complete the following
Legal Name of Entity:
Address
Street Address Address Line 2 City State ZIP Code
Entity Type
Website
FEIN
Total employees (including the Applicant)
Is the entity one hundred percent (100%) owned by the Applicant?
- Yes
- No

Practice Profile
Provide the following gross revenue figures and average weekly billable hours:
Last Fiscal Year
Fiscal Year Ending
Month
Day
Year
Gross Revenue
Average Weekly Billable Hours
Current/Next Fiscal Year (estimate)
Fiscal Year Ending
Month
Day
Year
Gross Revenue
Average Weekly Billable Hours
Provide the percentage of gross annual revenue derived from the Applicant’s professional services. Percentages entered in AREAS OF PRACTICE that contain an asterisk will require completion of additional questions pertaining to that specific area of practice.
NON-LAWYER LEGAL SERVICES/AREAS OF PRACTICE
Administrative Law
Please enter a number from 0 to 100.
Civil Law
Please enter a number from 0 to 100.
Criminal Law
Please enter a number from 0 to 100.
Family Law:
Divorce (under $1 million in marital assets)
Please enter a number from 0 to 100.
Divorce ($1 million or more in marital assets)
Please enter a number from 0 to 100.
Adoption
Please enter a number from 0 to 100.
Guardianship/Juvenile
Please enter a number from 0 to 100.
Other:
NON-LEGAL/OTHER SERVICES
Non-Legal Services
Please enter a number from 0 to 100.
Paralegal Services
Please enter a number from 0 to 100.
Legal Services
Please enter a number from 0 to 100.
Total %*
Percentages must total to 100% - Please Revise.
Does any client account for fifty percent (50%) or more of the Applicant’s gross annual revenue?
- Yes
- No
If “Yes,” complete the following
Name of client
Percentage of gross revenue
Services Performed

Professional Profile
List the Applicant’s active bar association memberships:
State Bar Admitted (Year)
List the Applicant’s professional qualifications:
Institution Degree Year Qualified

Risk Management
Does the Applicant regularly confirm representation in writing using formal engagement letters?
- Yes
- No
Does the Applicant utilize a diary or docket control system which tracks court dates, deadlines, statute of limitation dates or other time sensitive dates (i.e., closing dates, tax filings)?
- Yes
- No
How many suits for collection of fees have been filed by the Applicant during the past two years?

Insurance
Does the Applicant currently carry Professional Liability (Errors & Omissions) insurance?
- Yes
- No
If “Yes,” complete the following:
Expiring Policy Expiration Date:
Month
Day
Year
Expiring Policy Prior Acts Date:
Month
Day
Year
If “No,” complete the following:
Desired Effective Date of Coverage:
Month
Day
Year

Claims
In the past five years, has the Applicant been refused admission to practice law, disbarred, suspended or formally reprimanded, sanctioned or disciplined by any court or administrative agency?
- Yes
- No
If “Yes,” provide details:
In the past five years, have any professional liability claims or suits been made against the Applicant?
- Yes
- No
If “Yes” is selected, please complete additional questions in the CLAIM/SUIT/CIRCUMSTANCE section.
Is the Applicant aware of any fact, circumstance or situation which may reasonably be expected to give rise to a professional liability claim or suit against the Applicant?.
- Yes
- No
If “Yes” is selected, please complete additional questions in the CLAIM/SUIT/CIRCUMSTANCE section.
CLAIM/SUIT/CIRCUMSTANCE
Name of Claimant or Potential Claimant:
Claim Status:
- Open
- Closed
Date Reported:
Month
Day
Year
Describe the claim, suit and/or circumstances:
Provide the reserved and/or payment amounts made for this claim, suit or circumstance:
Reserve Amount By Insurer
Payment By Insurer
Deductible Payments By Applicant

THE APPLICANT AND FIRM ACCEPT NOTICE THAT ANY POLICY WHICH MAY BE ISSUED WILL APPLY ON A “CLAIMS MADE AND REPORTED” BASIS.

The undersigned authorized person, on behalf of the applicant, attests that to the best of the his/her knowledge and belief the statements set forth herein are true. Although the signing of this Application Form does not bind the undersigned to effect insurance, the undersigned agrees that this application and the said statements shall be the basis of the policy of insurance and deemed incorporated therein, should the Company evidence its acceptance of this application by issuance of a policy.

The undersigned authorized person on behalf of the applicant declares that the above statements are true, that neither the undersigned person nor the applicant has suppressed or misstated facts and that at the present time the applicant has no reason to anticipate any claims being brought against the applicant or any representative of the applicant or knowledge of any negligent act, error, omission or offense on the applicant’s part or any representative of the applicant except as stated herein, and agrees that this Application Form shall be the basis of the contract between the applicant and the Company and shall be deemed a part hereof.

Signing this form does not bind you to complete the insurance. Coverage will become effective upon approval of the appli- cation and issuance of the policy. It is agreed that this form will be the basis of the contract. Should a policy be issued, this form will be attached to and become a part of the policy.

The answers given to all questions in this application are complete and correct to the best of my knowledge.

FRAUD WARNING: 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 any 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 and subjects such person to criminal and civil penalties.
Date:
Month
Day
Year
APPLICANT’S NAME AND TITLE:
AGENT NAME:
AGENT LICENSE NUMBER:

Step 1 of 8

Qualifying Questionnaire

Applicant Information

Practice Profile

Professional Profile

Risk Management

Insurance

Claims

CLAIM/SUIT/CIRCUMSTANCE

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State Bar	Admitted (Year)

Institution	Degree	Year Qualified