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PART I
Name of Applicant:
Name of Law Firm:
City: State: Zip:
Telephone Number: Fax No:
Email Address:


PART II

Date and Year Admitted to
Oklahoma Bar Association		 /   /  

OBA Number:


A. If you are or have been a member of any other Bar Association, give State and Date Admitted to practice:
State: Date Admitted: /   /  
State: Date Admitted: /   /  
State: Date Admitted: /   /  

PART III
Date and Year proposed insured is to be added to policy: /   /  


PART IV

Has the 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
 
If answer is Yes, submit full particulars:

PART V

Have any claims or suits been made against the applicant?
Yes No

If answer is Yes, submit full details:
 

PART VI
Does the applicant know of any circumstance, act, error or omission which could form the basis for the assertion of a claim? You are answering this question, and if applicant knows of such circumstance, act, error or omission and does not report it, coverage may be voided and/or excluded.
Yes No

If answer is Yes, submit full details:


PART VII

Has any insurance for any applicant been declined, cancelled, specially rated, had the deductible increased, policy limits decreased or subject to a special endorsement restricting coverage?
 Yes No

If answer is Yes, submit full details:


PART VIII

Previous insurance (last 7 years); Including period of no coverage: (Mo/Day/Year)
 
Previous Firm
Carrier
Limits Each Claim/Aggregate
Effective Date From
Effective Date To


PART IX

Will the applicant be involved in securities regulatory practice?
Yes No

If Yes, please describe:


PART X

Has the applicant ever been convicted of a criminal offense, other than traffic offenses?
Yes No

 If yes, state the nature of the offense, the charge and the outcome:


PART XI

Is the applicant abusing drugs, alcohol or any chemical substance, or suffering from emotional distress?
Yes No

 If Yes, please describe:


I hereby declare that the above statements and particulars are true and that I have not suppressed or misstated any material facts and I 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:

 

**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