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Claims-made Policy Application
(This application will attach to and become a part of any policy issued.)

PART I

Firm Name
Partnership Individual Professional Corporation Professional Association

PART II

Firm Mailing Address:
City:		State:		Zip:

Federal Tax ID #
Telephone Number:
Fax No:
Contact Name
Email Address:

PART III

Date policy to be effective:

/ /

PART IV

Limits of Liability:

Deductible:

Additional PART IV (Optional) - If you would like multiple quotes, select additional "Limits of Liability" and/or "Deductibles" below:
Option 2

Limits of Liability:

Deductible:

Option 3

Limits of Liability:

Deductible:

PART V

List the name, specialty (to be selected by number from list in question 19*), bar affiliation, state and year admitted to practice for all:

A. Individual Practitioner:

Name	OBA Number	Specialty (using the numbers from PART XII)	States Admitted	Year and Month Admitted

B. Partner or Corporate Officers and Shareholders:

Name	OBA Number	Specialty (using the numbers from PART XII)	States Admitted	Year and Month Admitted

C. Other Employed Lawyers:

Name	OBA Number	Specialty (using the numbers from PART XII)	States Admitted	Year and Month Admitted

PART VI

A. Does an "Of Counsel" arrangement (or any association) exist with anyone?
Yes No
If Yes please provide the following:

Attorney's Name	OBA Number	Year and Month Admitted

Please describe:

B. Does the applicant have an office space and/or expense sharing arrangement with any other attorney?
Yes No
(If Yes, then please describe and submit a copy of your stationery along with this application).

PART VII

Has any applicant ever been reprimanded by or refused admission to practice, disbarred or suspended from practice before any court or administrative agency, subject of a grievance or any complaint filed with the Oklahoma Bar Association, or any other Bar organization?
Yes No Only those previously reported
If answer is Yes, submit full particulars:

PART VIII

Docket Control/Work Control System:
A. Does applicant have a planned system applicable to litigated and non-litigated matters with date deadlines?
Yes No
Please describe:

B. Does a cross-check or dual control exist?
Yes No
Please describe:

C. Does the ultimate responsibility for docket control/work rest with the attorney handling the matter?

Yes No

Conflict of Interest Control System:
D. Describe the firm's screening process for determining conflicts of interest, i.e. use of client list, etc:

Engagement Letters:
E. Are engagement letters used in all new matters, defining the scope of representation?
Yes No

F. Do engagement letters specify fee agreements?
Yes No

PART IX

Other Employment:
A. Is the applicant engaged in private practice? Yes No

B. Is the applicant employed by other than a law firm? Yes No
If yes, please list employer and describe duties performed:

Involvement in Financial Institutions:
C. Does or did any attorney manage, own (have interest in) or have financial control of, or is any attorney employed by a bank, trust company, mortgage and loan association, building or savings and loan association, title guaranty or real estate company?
Yes No
If Yes, please describe:

D. Are legal services provided to the institution referenced above?
Yes No

Outside Interests:
E. Is any firm member serving as a director, officer, trustee, partner, shareholder or employee of any entity other than the law firm?
Yes No
If Yes, please complete the following disclosure:

Firm Member	Name of Business	Position Held	Equity Interest (in %)	Firm Client	Director/Officer Insurance

PART X

A. Have any claims or suits been made against any applicants, their (his/her) predecessors in practice or any of the present partners, or to the knowledge of the firm, against any past partners?
Yes No Only those previously reported
If Yes, please provide full details:

B. Does any attorney or any employee in your firm know of any circumstance, act, error or omission that might constitute a breach of professional duty or responsibility which could form the basis for the assertion of a claim against any member or employee of your firm? You are answering this question for each attorney and employee in your firm, and if any of them knows of such circumstance, act, error or omission and you do not report it, coverage may be voided and/or excluded.
Yes No
If Yes, please provide full details:

C. Has any insurance for any applicant, present partners, associates or predecessors ever been declined or cancelled, specially rated, had the deductible increased, policy limits decreased or subject to a special endorsement restricting coverage?
Yes No
If Yes, please provide full details:

D. Has the firm filed suit against any clients in the past 12 months?
Yes No
If Yes, please provide full details:

E. Does any one client represent more than 50% of the firm’s annual gross income?
Yes No
If Yes, please list client and state nature of services:

F. Does the firm advertise in the mass media?
Yes No
If Yes, what is the annual advertising budget?

PART XI

A. What percent of the firm's practice was derived from matters handled in out-of-state jurisdictions over the past five years (or during the life of the firm if less than five years)? These matters are actually handled in out-of-state jurisdictions, not where clients are merely domiciled in other states.
%

B. During the next 12 month period, what percent of the firm's practice is expected to be matters handled in out-of-state jurisdictions?
%

PART XII

Indicate the percentage of gross billable dollars in the following areas of practice:

1. Negligence Plaintiff	%
2. Negligence Defendant	%
3. Civil Rights	%
4. Real Estate	%
5. Estates Trusts & Probate	%
6. Patents, Trademarks & Copyrights	%
7. Corporation & Business Org.	%
8. Local Government	%
9. Commercial & Business Trans.	%
10. Securities Activities*	%
11. Family	%
12. Immigration	%
13. Tax	%
14. Criminal	%
15. Bankruptcy	%
16. Collections	%
17. Oil & Gas	%
18. Environmental	%
19. Employment	%
20. Work Comp	%
21. SSI Disability	%
22. Other: Describe	%

*The Securities Act of 1933, The Securities Exchange Act of 1934, The Trust Indenture Act of 1939, The Investment Company Act of 1940, The Investment Advisors Act of 1940, The Public Utility Holding Company Act of 1935, or other Federal Securities Law, or in relation to any purchase, sale or offering of any security to or from the public which is covered or claimed to be covered by any State Blue Sky or Securities Law, or any Rules or Regulations issued pursuant to any of the aforementioned or any amendments or replacements thereof.

PART XIII

A. Are you aware of any attorney in the firm who is abusing drugs, alcohol or any chemical substance, or is suffering from emotional distress?
Yes No
If Yes, please give full details:

B. Have you or any of your firm members ever been convicted of a criminal offense, other than traffic offenses?
Yes No
If so, state the nature of the offense, the charge and outcome.

I/We hereby authorize any authorized agent of the Company to make an independent investigation with any and all regulatory agencies of the Oklahoma Bar Association or the other state agency or private source with impunity to any right of privacy under law or otherwise.

I/We hereby declare that the above statements and particulars are true and that I /We have not suppressed or misstated any material facts and I/We agree that this application shall be the basis of the contract with the Company.

It is understood and agreed that the completion of this application does not bind the Company to issue nor the applicant to purchase the insurance.

Name Firm:
Date of Application:
By:
Title:

**This application may be submitted by electronic means. In doing so, an application so submitted constitutes a written paper, and the electronic signature submitted will be considered an original signature, binding the applicant in all respects.

Oklahoma Attorneys Mutual Insurance Company
3900 S. Boulevard | P.O. Box 5590 | Edmond, OK 73083-5590
(405)471-5380 | (800)318-7505 | Fax (405)471-5381