Malpractice Application | Kaestner & Berry Insurance

Please complete the form and click on Submit.

Firm Name:

# of Attorneys:

Contact Name:

Firm Address:

City/State/Zip Code:

County:

Year Firm Established:

Email:

Phone:

Attorney Information:

Please input the information for each attorney in the box below:

Attorney’s Name, Bar Admission Date, Date Joined Firm, Relation to Firm, Number of Weekly Hours

If date joined firm is different than prior acts date, please advise.

Areas of Practice:

Please express percentages of the firm’s time devoted (billable hours) in each area during the previous year. Indicate the types of law you practice, not the business of the client you represent, and the percentage (in whole numbers up to 3 digits). The total must equal 100%.

Admiralty:

Arbitration:

Banking/Financial Institutions:

Bankruptcy:

Civil Rights/Discrimination:

Commercial Litigation Defense:

Commercial Litigation Plaintiff:

Consumer Claims/Collections:

Construction:

Criminal/Traffic:

Environmental:

Family Law:

General Corporate/Business Transactions:

Government:

Immigration and Naturalization:

Insurance Defense:

Intellectual Property (Copyright/Trademark/Patent):

Labor Law – Employee/Union:

Labor Law – Management Representation:

Personal Injury/Property Damage Defense:

Plaintiff – Bodily Injury/Property Damage:

Plaintiff – Medical Malpractice:

Plaintiff – Workers Compensation:

Plaintiff – Class Action/Mass Tort:

Real Estate Commercial:

Real Estate Residential:

School Law:

Securities (SEC):

Tax:

Wills, Estates, Probate & Planning:

Other - Please explain:

Total % (must be 100%):

Insurance History

Does your firm currently have liability coverage?

Yes

If yes, please fill in the information below.

Carrier:

Expiration Date:

Retroactive Date (Prior Acts):

Limit $ per claim:

Limit aggregate:

Deductible:

Firm Management

Does your firm have a dual docket system?

Yes

Does your firm have a conflict system?

Yes

Does your firm handle mass tort or class action work?

Yes

Does your firm have any one client who represents more than 25% of the firm’s billing?

Yes

Number of suits for fees filed against clients in the past three years:

Claim/Potential Claim/Bar Complaint History

In the last 5 years have any past or present personnel:

a) Been the subject of a bar complaint, grievance, disciplinary action or denied the right to practice law?

Yes

b) Know of any professional liability claim made against the Applicant, its affiliates or its personnel or become aware of any circumstance which might become the basis of a claim?

Yes

If yes to questions a or b, please complete a separate Claim Supplement for each one from the last five years. You will receive a confirmation with a link to the online Claim Supplement after you submit this application.

Please type signature:

Date:

When the form is complete, click on Submit.