Parsons & Associates, Inc.
(800) 440-9932

 

New York Questionnaire For Lawyers Professional Liability Insurance

This questionnaire is ONLY to be used for the conversion of existing insurance programs being non-renewed for reasons other than claims and/or practice area exposure. Submission must also contain the required additional documentation requested under the Conversion Questionnaire Checklist (below). This questionnaire DOES NOT replace a CNA New Business Application.

    
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Privacy Statement: Any information provided by a consumer or customer via our online forms WILL be held in the strictest confidence. No information will be shared with others. Our goal is to respond to all submissions within two business days.

We only accept inquiries for insurance written in New York State

QUESTIONNAIRE CHECKLIST
 
Following this checklist will help to speed up the processing:
  1. Make sure all the questions are answered
  2. Additional information required:
    1. Letterhead is required and MUST match the requested named insured indicated in question #1 on the application.
    2. Expiring dec page
    3. Expiring firm specific endorsements
    4. Currently dated 5 year loss run
    5. Sample engagement letter
  3. Any "YES" answers to some questions (as noted) require additional supplements and/or action. Please note that you will also be given a list of links for any supplemental forms that you must complete on the confirmation page that appears after your submission.

 

 About The Firm
  1.   The precise registered name of the applicant firm to be insured, as reflected on the firm's letterhead:
 Firm Name: 
  2.   Firm Address:    City:   State:   Zip:
  3.   Firm Phone#: 
  4.   Firm Web Address: 
  5.   Effective Date:  / /
  6.   What year was the firm established?:  / /
  7.   Type of Entity:  solo practitioner    individual attorney w/ employee attorney(s)    partnership    PC    PA    LLC    LLP    other
  8.   Is the firm office or suites shared with attorneys other than firm members?:   Yes   No    
  9.   Does the firm have offices at locations other than the primary location?:   Yes   No    
 10.   Does the firm practice in multiple states?:   Yes   No    
 11.   Is the ratio of support staff to attorneys greater than 3 to 1?:   Yes   No    
 12.   For how many years has the firm been continuously insured for malpractice claims?:       
 13.  Current Carrier:     Current Coverage Limits: $     Deductible: $     Premium: $
 14.   Has the firm ever purchased an Extended Reporting Period (Tail) option?:   Yes   No    
 15.   Has the firm's coverage ever been non-renewed, cancelled, rescinded or declined by another carrier?:   Yes   No    
 16.   Does the firm desire coverage for any previously-dissolved predecessor firms and those attorneys affiliated therewith?:   Yes   No    

 

 Areas of Practice
  Guidelines for completing this section: 
  1. Express percentages of time devoted (billable hours) in each during the previous year.
  2. Indicate percentages in whole numbers next to the type of law you practice, not the business of the client you represent.
  3. Please be as accurate as possible, as casual estimates may cause inappropriate evaluation of your practice.
  4. All litigation should be coded as "Civil Litigation" with the exception of "Criminal", "Personal Injury" and "Intellectual Property" which should be coded to their respective Area of Practice.
    % Admiralty/Marine-Defense
% Admiralty/Marine-Plaintiff
% Anti-Trust Trade Regulation
% Banking/Financial Institutions
% Business Transaction / Commercial Law
% Civil/Comm'l Litigation-Defense
% * Civil/Comm'l Litigation-Plaintiff
% Civil Rights/Discrimination
% Collection and Bankruptcy
% Construction (Building Contracts)
% Consumer Claims
% Corporate Business Organization 		% Criminal
% Environmental Law
% Family Law
% Government Contracts/Claims
% Immigration/Naturalization
% * Intellectual Property (Patent, Trademark)
% International Law
% Labor Management Rep
% Labor Union Rep
% Local Government
% Natural Resources/Oil and Gas 		% Personal Injury/Property Damage-Defense
% * Personal Injury/Property Damage-Plaintiff
% Real Estate/Title-Commercial
% Real Estate/Title-Residential
% * Securities (SEC)
% Taxation
% Wills, Estates, Probate & Planning
% Workers' Compensation-Defense
% Workers' Compensation-Plaintiff
% Other -- (please describe below)
      Total (Must equal 100%): % 

 

 Firm Operations and Management
 17.   Does the firm or any attorney of the firm have clients in the Entertainment industry?:   Yes   No    
 18.   Does the firm have:   
   a. Any one client in which the firm's attorneys have an equity interest greater than 10% combined?:   Yes   No    
   b. Any one client which represents more than 25% or more of the firm's billings?:   Yes   No    
   c. Anyone in the firm serve as a director, officer or employee or in any other management capacity for a client?:   Yes   No    
 19.   Does the firm have procedures for identifying and resolving potential or actual conflicts of interest including cross-checking of former, existing
 or potential clients?: 		  Yes   No    
 20.   Does the firm have at least two independently maintained docket controls?:   Yes   No    
 21.   a. Does the firm regularly confirm representations in writing via use of formal engagement letters?:   Yes   No    
   b. Does the engagement letter include the following:   
        • Identity of the Client?:   Yes   No    
        • Scope of Representation that includes key terms of legal representation?:   Yes   No    
        • Fee structures and billing agreements?:   Yes   No    
        • Termination agreement that includes file retention and destruction terms?:   Yes   No    
   c. Does the firm ensure that a countersigned engagement letter is received from the client before work begins on a new matter?:   Yes   No    
 22.   Does the firm regularly acknowledge in writing the declination or termination of representations?:   Yes   No    
 23.   For firms greater than 5 attorneys: Does the firm require that at least two attorneys in the firm be informed of the initiation of a representation?:   Yes   n/a    
 24.   If you are a solo practitioner, do you have a procedure in place regarding provisions of services if you are incapacitated or otherwise unavailable?:   Yes   n/a    
 25.   Has the Firm initiated lawsuits or arbitration during the last two years to enforce the collection of unpaid fees for the firm?:   Yes   No    
 26.   Has the Firm or any lawyer in the Firm represented publicly traded clients with services rendered involving Sarbanes-Oxley Act (SOX)
 compliance including but not limited to Securities, Accounting, Financial/Investment Services or Tax work?:  		 Yes   No    
 27.   In the past 5 years, has the firm become involved in any mass tort / class action cases?:   Yes   No    
 28.   Provide the firms estimated gross revenues for the current fiscal year: 

 Year  Year End Date  Gross Revenues
 Current fiscal    $
 
 29.   What percentage of accounts receivable are outstanding more than 90 days?:   %    

 

 Attorney Schedule
 Total number of attorneys: List all of the firm's attorneys. Differences between the date attorney began practicing law for other than a corporate or governmental entity and
 the date the attorney was admitted to the Bar must be explained in the "Other" section.
Attorney
Name		 Attorney/
Partner
Designations		 Avg #
hours
per week		 States licensed
to practice law		 # of Years Prior
acts date		 CNA Risk Mgmt
(through
WestLegal Ed)		 NY State
Bar Assoc
Member?
In
Practice		 With
this firm		 Continuous
malpractice
coverage
YN
YN
YN
YN
YN
YN
YN
YN
YN
YN
 Other: Please provide any additional pertinent information.
  

 

 Signature and Representation
 The information contained herein and in any supplemental applications or forms required, is true, accurate and complete and that no material facts have been suppressed
 or misstated.
 Applicant hereby authorizes the release of claim information to the Company from any current or prior insurer of the Applicant.
        By  Check box if you agree w/ signature statement
*** SIGNATURE STATEMENT ***
 I am authorized and agree to use electronic signatures to sign this
 application. By checking the box below, I agree to transact business using
 electronic communications, electronic records, and electronic signature
 rather than paper documents.


Signature of Officer or Partner of the Firm
    
Print Name of Officer or Partner
    
Email Address
    
Date
    
 Broker Information
   
Broker Agency Name
  
Contact Name
  
Contact Email
  
Contact Phone
  
 Direct Questions or Correspondence To:
  Parsons & Associates, Inc.             440 S Warren St Ste 704, Syracuse NY 13202-2656
(877) 452-9776 - Fax (315) 472-3222 		            E-Mail: info@parsonsinsurance.com
Website: www.ParsonsInsurance.com 		 

 
Please click on the "Submit Application" button to send your form.

Please Note: You will be given a list of links for any supplemental forms that you must complete on the confirmation page after your submission.

One of our representatives will respond to your submission as soon as possible.

   

 
 
 
PARSONS & ASSOCIATES

The Galleries of Syracuse
440 S Warren St Ste 704
Syracuse NY 13202-2656
 

                        GIVE US A CALL

Telephone: (315) 472-5420
Toll Free: (800) 440-9932
FAX: (315) 472-3222
Toll Free Fax: (877) 472-8465
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Please Note: This website is intended to present a general overview for illustrative purposes only. It is not intended to constitute a binding contract. Please remember that only the relevant insurance policy can provide the actual terms, coverages, amounts, conditions and exclusions for an insured. Insurance coverages may not be changed or added by email request. They must be confirmed by a representative from Parsons & Associates, Inc.