TEXAS LAWYERS' INSURANCE EXCHANGE ELECTRONIC FORMS: ATTORNEY NOT CURRENTLY INSURED BY TLIE The forms included in this file are as follows: NEW BUSINESS APPLICATION ATTORNEY INFORMATION SUPPLEMENT OF COUNSEL SUPPLEMENT FINANCIAL INSTITUTION SUPPLEMENT EQUITY INTEREST SUPPLEMENT SECURITIES ACTIVITIES SUPPLEMENT CLAIM INFORMATION SUPPLEMENT Each form is separated by a page break. Here are a few suggestions for using the text only forms available from TLIE either on disk of from our website at tlie.org. We do not encourage emailing your application at this time. We need a signature on the application. If you have a method of digitally signing the document, contact us about the method you wish to use. You can send in an application by email to info@tlie.org and send in the signed version by regular mail or fax if you wish. Faxed applications are accepted. We can always read Microsoft Word and rtf formatted files; some Word Perfect files are not compatible with our software at present. We have used as little formatting as possible, using a rtf (rich text) format. This should work major PC, Mac and Unix word processors. We avoided using line breaks, and tried to use only paragraph formatting at the end of a natural paragraph. Your word processor should have the ability to simply wrap lines as the length of a line reaches the edge of the page. In some word processors, you have to choose an option to force "word wrap." In a couple of cases, we did use tabs set at 1/2inch intervals. The most significant of these was the listing of limit and deductible options. Do not worry if you can't get the tabs exactly right on the limit option section; you can put X's in desired boxes or just tell us what limits and deductibles you want if that section looks too strange on your machine. We have looked at these forms in Times New Roman Truetype fonts on Windows, at 10 points. Switching to that font might make any oddly formatted areas clearer. Feel free to use any font you wish. To use a form or forms, open your word processor first. Open the form you want from inside the word processor the first time. You may then want to save the file as a document in your word processor to allow you to choose the fonts and formatting that you wish. We suggest you not alter the original text file, so that if you accidentally delete part of a form you can recreate it quickly. In addition, some forms may have to be used more than once. Cutting and pasting parts of a form to make what would be multiple copies of the same form into one document is perfectly acceptable. If you downloaded one of the packages of forms from our website, then all of the forms are a single document. You may want to separate each form into separate documents in your word processor, though you don't have to do that. We have formatted a page break between each document. You can simply print out the entire package when finished and discard those parts which were not necessary to complete the application. Where brackets are used for either yes or no questions or check boxes, please move your cursor to the inside of the brackets and mark with an "X" if necessary. You can also print out the form and handwrite any thing you wish; you won't have the advantage of having a copy of your previous year's application the next time around, however. Some of the information requested may be best typed into a table, such as lists of attorneys in a larger firm. We have not formatted any tables, since word processors vary so much in their treatment of tables. If you want to create a table and have it show information requested, please feel free to do so. If an explanation of any answer is necessary, you can either type it right after the question or type a separate sheet-whichever is easier for you. Please do not delete either the title of the forms or the last line of the forms. These tell us if you have an outdated form for some reason. If you get stuck on either a technical problem or a substantive one, please call us at 1-800-252-9332 or email info@tlie.org. TLIE Forms Intro Ver. 2 TEXAS LAWYERS' INSURANCE EXCHANGE Application for Attorneys' Claims Made Professional Liability Insurance Policy Please complete and forward to Texas Lawyers' Insurance Exchange, P. O. Box 13325, Austin, TX 78711 NOTE: Please complete and return in prepaid envelope All Questions Must Be Answered and Required Supplements Must Be Completed to Avoid a Delay in Processing Your Application. If answer is "none," state "none" or "N/A," instead of leaving a blank. INITIAL INFORMATION ABOUT YOUR PRACTICE 1. Who should we contact first if we have a question about your application? 2. ATTACH A COPY OF THE APPLICANT'S LETTERHEAD. If new letterhead is not yet available, please attach a typed version of your anticipated letterhead. 3. (a) Full name of applicant for insurance: Date firm established: Tax Payer ID# (b) Check type of practice: [ ] Individual [ ] L.L.P. [ ] Partnership [ ] P.L.L.C. [ ] Joint Venture [ ] Other (please specify) 4. (a) Principal Office Mailing Address: Street: P. O. Box: City: State: Zip: Phone: ( ) FAX: ( ) [ ] CHECK HERE IF BILLING AND POLICY INFORMATION SHOULD BE SENT TO A DIFFERENT ADDRESS, AND PROVIDE THE ADDRESS BELOW. (b) Number of offices? If more than one, list addresses below if not shown on letterhead submitted. 5. Are there any firms, in addition to the one named in response to Question 3, that you want to have covered by the insurance for which you are applying? Do not include single attorney professional corporations practicing within the firm. [ ] YES [ ]NO If yes, list each firm name, dates that the firm existed, and the approximate number of attorneys associated with the firm. If a firm name is merely a prior name for the firm listed in Question 3 and no new entity was created when the name was changed, you need only note that there was a name change. ONLY FIRMS LISTED OR DEFINED AS INSUREDS IN A POLICY WILL BE COVERED BY THE POLICY. Single attorney professional corporations practicing under the Named Insured are defined as Insureds in the policy. INFORMATION ABOUT ATTORNEYS 6. Complete the portion of the Attorney Information Supplement which requests information about each attorney for whom insurance coverage is desired. You may provide the information requested by the supplement on your own form if it provides the information requested. ATTORNEYS LISTED ON THE SUPPLEMENT ARE REFERRED TO AS FIRM MEMBERS IN OTHER QUESTIONS ON THE APPLICATION. Have 75% of firm members listed in the attorney information supplement completed a TLIE sponsored seminar since the last application? [ ] YES [ ] NO 7. Complete the portion of the Attorney Information Supplement which requests information about the employment history of the attorney since they were licensed. Please include all time periods since the attorney was licensed, including corporate and government employment. You may provide the information requested by the supplement on your own form if it provides the information requested. 8. Provide the following information for each attorney who left the applicant within the last year. Attorney's Name: Date Attorney Joined Firm: Date Attorney Left Firm: 9. Do any attorneys act as "Of Counsel" to the applicant? [ ] YES [ ] NO If yes, complete the Supplemental Of Counsel Information Form. NATURE OF YOUR PRACTICE 10. If you are a solo attorney currently averaging less than 25 hours per week in actual practice, please complete the following: Average hours per week currently: Average hours per week last year: Average hours per week 2 years ago: Average hours per week 3 years ago: Average hours per week 4 years ago: 11. If you are a solo attorney currently working exclusively or primarily as a contract attorney, please complete the following: Is your entire practice currently only as a contract attorney? [ ] YES [ ] NO How many years in the past 4 have you worked exclusively as a contract attorney? 12. Does any attorney other than firm members share office space or expenses with the firm? [ ] YES [ ] NO If yes, provide the following information about each of those attorneys: Attorney's Name: Bar Card Number: Date Office/Expense Sharing Began: 13. List the percentage of time devoted by the applicant to specific areas of practice. The total must equal 100%. (a) Commercial Real Estate, not including foreclosures. (b) Foreclosures on real estate. (c) Any real estate other than (a) or (b) (d) General business other than real estate (includes collections, business organization, sale of businesses, banking, commercial disputes, etc.) (e) Fiduciary other than foreclosure sales. (f) Securities law. IF ANY TIME IS LISTED FOR THIS AREA, COMPLETE THE SECURITIES SUPPLEMENT. (g) Estate, trust and probate law. (h) Family law (i) Representation of persons: (a) seeking damages for bodily injury or personal injury. Workers' compensation and products liability representation are included in this category; (b) seeking other affirmative relief under civil law. (j) Defense in civil matters. (k) Criminal law. (l) Other (list). 14. Has any firm member or any attorney who was a member of any entity listed in response to questions 3 or 5 or listed in the Attorney Supplement served as a director or officer of a financial institution, or provided legal services to any financial institution in the past 10 years? Answer "Yes" even if the financial institution is no longer a client of the firm or the attorney who provided services is no longer with your firm. [ ] YES [ ] NO If yes, complete a SUPPLEMENTAL FINANCIAL INSTITUTION INFORMATION FORM for each institution. Financial institutions include savings and loans, banks, credit unions, savings associations, and building and loan associations, as well as service companies, subsidiaries, and parent companies of such entities. FIRM POLICIES AND PROCEDURES MOST OF THE QUESTIONS IN THE FOLLOWING SECTION SEEK INFORMATION ABOUT PRACTICES OR LACK OF CONTROLS THAT CAN LEAD TO A GREATER RISK OF LEGAL MALPRACTICE CLAIMS. 15. Does the applicant participate in or own an interest in a joint venture or subsidiary to provide specialized services to one or more clients? [ ]YES [ ]NO If yes, complete an EQUITY INTEREST SUPPLEMENT. 16. Has the applicant or any firm member represented any clients in which firm members have an equity interest or in which a firm member is an officer, director or employee? Include interests in title companies for which the applicant provides legal services. [ ] YES [ ] NO If yes, complete an EQUITY INTEREST SUPPLEMENT. 17. Is the applicant or any firm member a licensed escrow officer? [ ]YES [ ]NO If yes, provide a copy of any agreements with title companies that include an indemnity or hold harmless agreements. If yes, how many non-attorney licensed escrow officers are employed by the applicant? 18. Does any firm member perform legal services as an employee of a governmental body, a company, or any other person other than the person or entity named in Question 3? [ ] YES [ ] NO If yes, provide details. 19. Has the applicant or any firm member ever acted as an investment manager or advisor for any client or ever had discretionary authority over the funds of any client? [ ] YES [ ] NO If yes, provide details. 20. If the applicant is an individual, who is responsible for your practice in the event of a prolonged absence? 21. Does the applicant have written policies and procedures regarding scheduling of work, deadlines, and appointments? [ ] YES [ ] NO If yes, provide a copy. If no, please describe the manner in which scheduling is handled in the office, including which persons keep track of a schedule. 22. Does the applicant have written policies regarding avoidance of conflicts of interest? [ ] YES [ ] NO If yes, provide copies. Please include policies regarding business dealings with clients and service as an officer or director for a client. If no, describe the methods used to avoid conflicts of interest, or check which of the following methods you use: [ ] Memory [ ]Discussion with other firm members [ ] Computer [ ] Index files [ ] Interoffice Memos. 23. Does the applicant have a written policy regarding filing suits against clients for fees? [ ] YES [ ] NO If yes, provide a copy. If no, has the firm filed any suits for fees against clients in the past 3 years? [ ] YES [ ] NO INSURANCE LIMITS AND DEDUCTIBLES DESIRED 24. TLIE offers the following policies. Please refer to the information enclosed with your application or call us with questions. On the limit and deductible choices, if a second number is shown, the first number is the per claim limit or deductible and the second is the aggregate limit or deductible for the policy year. TLIE Regular Policy Please indicate below the limits of liability and deductible(s) for which you would like to receive quotations. LIMITS OF LIABILITY DEDUCTIBLE $ Per Claim/Aggregate $ Per Policy Year [ ] 100,000 1K[ ] 3K[ ] 5K[ ] 10K[ ] [ ] 100,000/300,000 1K[ ] 3K[ ] 5K[ ] 10K[ ] [ ] 200,000/600,000 1K[ ] 3K[ ] 5K[ ] 10K[ ] [ ] 500,000 1K[ ] 3K[ ] 5K[ ] 10K[ ] 25K[ ] 50K[ ] 100K[ ] [ ] 500,000/1,000,000 1K[ ] 3K[ ] 5K[ ] 10K[ ] 25K[ ] 50K[ ] 100K[ ] [ ] 1,000,000 1K[ ] 3K[ ] 5K[ ] 10K[ ] 25K[ ] 50K[ ] 100K[ ] [ ] 2,000,000 1K[ ] 3K[ ] 5K[ ] 10K[ ] 25K[ ] 50K[ ] 100K[ ] 100K/300K[ ] 250K[ ] [ ] 3,000,000 1K[ ] 3K[ ] 5K[ ] 10K[ ] 25K[ ] 50K[ ] 100K[ ] 100K/300K[ ] 250K[ ] [ ] 4,000,000 1K[ ] 3K[ ] 5K[ ] 10K[ ] 25K[ ] 50K[ ] 100K[ ] 100K/300K[ ] 250K[ ] 250K/750K[ ] 500K[ ] [ ] 5,000,000 1K[ ] 3K[ ] 5K[ ] 10K[ ] 25K[ ] 50K[ ] 100K[ ] 100K/300K[ ] 250K[ ] 250K/750K[ ] 500K[ ] 500K/1,000K[ ] [ ] 10,000,000 1K[ ] 3K[ ] 5K[ ] 10K[ ] 25K[ ] 50K[ ] 100K[ ] 100K/300K[ ] 250K[ ] 250K/750K[ ] 500K[ ] 500K/1,000K[ ] [ ] Other Limits (specify): THE BASIC POLICY Limits of Liability Deductible $ Per Claim/Aggregate $ Per Policy Year [ ] 100,000/300,000 1K[ ] [ ] 200,000/600,000 1K[ ] [ ] 500,000/500,000 1K[ ] NEW ATTORNEY BASIC POLICY* Limits of Liability Deductible $ Per Claim/Aggregate $ Per Policy Year [ ] 100,000/300,000 1K[ ] *You must have been practicing for less than 4 years to qualify for this option. PART-TIME BASIC POLICY* Limits of Liability Deductible $ Per Claim/Aggregate $ Per Policy Year [ ] 100,000/300,000 1K[ ] *You must have completed Question 10 to qualify for this option. CONTRACT ATTORNEY BASIC POLICY* Limits of Liability Deductible $ Per Claim/Aggregate $ Per Policy Year [ ] 100,000/300,000 1K[ ] *You must have completed Question 11 to qualify for this option. REFERRAL SERVICE ONLY BASIC POLICY* Limits of Liability Deductible $ Per Claim/Aggregate $ Per Policy Year [ ] 100,000/300,000 1K[ ] NAME OF REFERRAL SERVICE: *Only certain referral services qualify for coverage. INSURANCE AND LIABILITY HISTORY ALL REPRESENTATIONS IN THIS APPLICATION ARE MADE ON BEHALF OF ALL FIRM MEMBERS AND ON BEHALF OF THE ENTITY OR ENTITIES APPLYING FOR INSURANCE. THE FOLLOWING QUESTIONS SHOULD BE ANSWERED BY THE PERSON SIGNING THE APPLICATION ONLY IF RECENT INQUIRY HAS BEEN MADE TO FIRM MEMBERS AND NON-ATTORNEYS EMPLOYED BY THE APPLICANT ABOUT THEIR KNOWLEDGE OF ANSWERS TO THE QUESTIONS. BOTH FIRM MEMBERS AND EMPLOYEES (INCLUDING NON-ATTORNEYS) OF THE APPLICANT MUST SUPPLEMENT THE ANSWERS TO THESE QUESTIONS AS CIRCUMSTANCES CHANGE UNTIL ISSUANCE OF A POLICY. 25. List the information requested about professional liability insurance policies issued to the applicant in the past four years, beginning with any coverage currently in force. Insurance Company: Limits: Deductible: Expiration Date: Premium: Give effective dates for any Extended Reporting Tail Options purchased: PLEASE PROVIDE THE PRIOR ACTS OR RETROACTIVE DATE ON Y0UR CURRENT POLICY: 26. Is the firm or any firm member ever had professional liability insurance cancelled, declined, or not renewed? [ ] YES [ ] NO If yes, provide a copy. 27. Has the firm or any firm member ever been the subject of a professional liability claim? [ ] YES [ ] NO If yes, complete SUPPLEMENTAL CLAIM INFORMATION FORMS. 28. Does any firm member, or any employee (including non-attorneys) of the applicant know, have reason to know, or have any basis to believe that a circumstance, act, error or omission might reasonably be expected to be the basis for the assertion of a professional liability claim against the firm or any attorney listed on the Attorney Information Supplement? [ ] YES [ ] NO If yes, attach a SUPPLEMENTAL CLAIM INFORMATION FORM. Any such matters should be reported to your current insurer and will not be covered under a subsequent TLIE policy. 29. Has any firm member had a grievance filed against him or her in the past five years? [ ] YES [ ] NO If yes, attach a copy of the grievance, a description of the circumstances of the grievance, and the status or outcome of any grievance proceeding. 30. Has any firm member ever voluntarily accepted discipline or been refused admission to the bar, reprimanded (privately or publicly), suspended from the practice of law, disbarred or otherwise disciplined by any disciplinary or licensing authority? [ ] YES [ ] NO If yes, provide full details. NOTE: Before Signing this Application, Please Check to be Sure that All Questions are Completely Answered, Appropriate Supplements are Completed and You have Attached a Copy of Your Firm's Letterhead. WARRANTY On behalf of the applicant(s) and all firm members and employees of the applicant(s), I/we hereby warrant and declare that the foregoing 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 Association; and it is agreed that all representations contained herein are material as a matter of law, and that I/we will immediately notify the Association, said representations being deemed continuous, of any change in facts occurring prior to issuance of insurance pursuant hereto. On behalf of the applicant(s) and all firm members and employees of the applicant(s), I/we hereby authorize release to the Association or its authorized representative, by any State Bar Association, my/our present and prior professional liability insurance carriers, or any other sources, any claims, underwriting, or other information having a bearing upon my/our acceptability as a professional liability insurance risk. It is understood that this is an application for insurance and not an insurance binder. CAUTION: Any misstatements made in this application could invalidate any policy issued on the basis of this application. Applicant Name: Date: Printed Name and Position: Authorized Signature: SUBSCRIBER'S AGREEMENT AND POWER OF ATTORNEY The undersigned, hereafter known as the Subscriber, agrees with other subscribers at an Exchange known as the TEXAS LAWYERS' INSURANCE EXCHANGE, hereinafter referred to as the Association, located in Austin, Texas, to exchange private contracts of indemnity. To that end, I hereby appoint the President of the Association and/or such person or persons as may be designated by the Board of Directors in accordance with Section 8, Article VIII of the Bylaws, and licensed by the Commissioner of Insurance of the State of Texas, with full powers of substitution and revocation, and with authority to act jointly or severally, as my Attorney-in-Fact, in my name, place and stead, to represent me in the following matters: 1. To exchange with other subscribers at such Exchange, insurance coverages as now or hereafter authorized by the Board of Directors; to subscribe and deliver all proper contracts of insurance; to take any action in furtherance of the exchange of such contracts of insurance; to do and perform every other thing that I could do in respect to such contracts so exchanged, including the appearance and defense in my name in actions and proceedings; and to manage and conduct the business, affairs and property of the Exchange under the supervision of the Board of Directors. 2. The powers hereby vested in my said attorney shall be exercised only in accord with the decisions of the Board of Directors of the Association, provided that the said attorney may deputize such person or persons as may be appointed therefore by the Board of Directors of the Association, to authenticate the policy contracts now applied for or those that I may hereafter apply for, and all papers pertaining thereto. It is understood that the subscribers reserve unto themselves the right to govern the Association according to the decision of a majority of subscribers present in person or by proxy at any meeting. 3. I adopt as a part of this agreement the Bylaws of the Exchange now or hereafter effective. 4. I agree that this Power of Attorney shall have application to all insurance applied for by me, including such modifications or changes in any of my insurance as may be made at my request, and the representations made by me in connection with each policy shall have the same force and effect as if contained in this instrument. 5. I agree that to the fullest extent now or hereafter permitted by law, no director of the Exchange shall be personally liable to the Exchange or to its Subscribers for monetary damages for any act or omission in the director's capacity as a director except liability for (i) a breach of a director's duty of loyalty to the Exchange or its Subscribers, (ii) an act or omission not in good faith or that involves intentional misconduct or a knowing violation of the law, (iii) a transaction from which a director received an improper benefit, whether or not the benefit resulted from an action taken within the scope of the director's office, (iv) an act or omission for which the liability of a director is expressly provided for by statute, or (v) an act related to an unlawful stock repurchase or payment of a dividend. Any repeal or modification of the foregoing paragraph by the Subscribers of the Exchange shall not adversely affect any right or protection of a director of the Exchange existing at the time of such repeal or modification. The effective date of the limitation of liability provided by this paragraph shall be the due date of member approval of this Paragraph 5. 6. I agree further that this Power of Attorney shall be and become effective on the date hereof, and shall remain in force and effect only so long as I have a contract of insurance with the Exchange. This power of attorney shall not terminate on disability of the principal. This agreement is strictly limited to the use and the purpose herein expressed and to no other purpose. Date: Applicant Name: Authorized Signature: TLIE Forms New App Ver. 2 ATTORNEY INFORMATION SUPPLEMENT Name of Applicant: Use the following abbreviations for positions: A-Associate, OC-Of Counsel, O- Officer, S-Sole Practitioner, P-Partner, E-Employed or Contract Attorney, M- Member of PLLC. Provide the information listed below for each attorney, including those individual attorneys operating as a professional corporation within a firm, for whom insurance coverage is desired. 1. Name 2. Bar card number 3. Position 4. Years in private practice 5. Primary area of practice 6. Month and year licensed 7. State where practising 8. Hours per week if not full time. Feel free to create a table for this information. Provide the following information for each attorney listed in response to the previous questions. 1. Attorney name 2. Date joined applicant 3. All former employers or firms since the attorney was licensed 4. Position with each employer or firm 5. Dates of employment at each employer or firm. Feel free to create a table for this information. TLIE Forms Attorney Supplement Ver. 2 SUPPLEMENTAL OF COUNSEL INFORMATION Applicant's Instructions: COMPLETE ONE FORM FOR EACH OF COUNSEL. Answer all questions COMPLETELY. (Please Type or Print) 1. Who is the person acting "Of Counsel" to your firm? (If there is more than one person acting in such a capacity, please fill out a separate form for each). a. Attorney's Name: b. Year Attorney became "Of Counsel": c. Bar Card # 2. How many hours per week does the person acting "Of Counsel" work for your firm? 3. In the past twelve months, how many hours did the person acting "Of Counsel" bill on behalf of your firm? Answer Question #4 only if the "Of Counsel" has been acting in that capacity for less than twelve months. 4. If the person acting "Of Counsel" to your firm has been acting in that capacity for less than twelve months, how many hours do you estimate that the "Of Counsel" will bill on behalf of your firm during their first year as "Of Counsel"? 5. Does the person acting "Of Counsel" to your firm also practice independently from your firm? YES [ ] NO [ ] If Your answer to question #5 was "No," proceed to question #7. 6. If your answer to question #5 was "Yes," please advise: Where does the person acting "Of Counsel" practice independently from your firm? Please provide the name and address of that firm. 7. Does the person acting "Of Counsel" to your firm carry any professional liability insurance? YES [ ] NO [ ] If your answer to question #7 was "No," proceed to question #9. 8. If your answer to question #7 was "Yes," please advise: a. With which company does the "Of Counsel" carry their own insurance? b. What are the effective dates of that policy? c. What are the limits of liability of that policy? Answer questions #9-11 with regard to the "Of Counsel" work on behalf of your firm: 9. Does the person acting "Of Counsel" to your firm appear in court? YES [ ] NO [ ] 10. Does the person acting "Of Counsel" to your firm sign pleadings? YES [ ] NO [ ] 11. Does the person acting "Of Counsel" to your firm have direct contact with clients? YES [ ] NO [ ] TLIE Forms Of Counsel Ver. 2 SUPPLEMENTAL FINANCIAL INSTITUTION INFORMATION Complete a separate form for each financial institution. Institution: Location: Has any firm member served as an officer or director? YES [ ] NO [ ] If yes, please give name(s) and dates. Has any firm member served on a loan or investment committee? YES [ ] NO [ ] If yes, please give name(s) and dates. Has any firm member had an ownership interest? YES [ ] NO [ ] If yes, please give name(s) and percent owned. Legal Representation Please give the names of all firm members who have provided legal services and the dates or period of time over which such services were provided: Please indicate the types of legal services that have been provided: Real Estate: [ ] Original Loan Documentation [ ] General Counsel [ ] Commercial [ ] Litigation [ ] Residential [ ] Collections [ ] Workouts [ ] Regulatory Compliance [ ] Other Legal Services (describe) [ ] Transactions involving the sale or transfer of delinquent or non-performing loans, loans on a watch list, or loans for acquisition, development and construction to another financial institution [ ] Other Real Estate (describe) I understand this information becomes a part of my Professional Liability Insurance Application and is subject to the same warranty and conditions. Signature of Applicant ________________________________ Date ___________ TLIE Forms Financial Institutions Ver. 2 EQUITY INTEREST SUPPLEMENT Applicant: Provide the following information for each client in which firm members have an equity interest or in which any firm member is an officer or director. Financial institutions do not need to be reported on this form. Financial institutions must be reported on the Supplemental Financial Institution Information Form. 1. Name of Client/Business Venture: 2. Attorney(s) With Interest: 3. Offices Held: 4. % of Interest: 5. Nature of Business: Feel free to create a table for this information. Have written disclosures of potential conflicts of interest been provided by the firm to the client in each of these situations? [ ] YES [ ] NO TLIE Forms Equities Ver. 2 SECURITIES SUPPLEMENT Name of Applicant: Indicate whether any of the following securities activities are part of the applicant's practice and the percentage of the practice if greater than zero. The total percentage of securities activities must equal the percentage reported in response to Question 11(f) on the main application. Public Offering of Securities [ ] YES [ ] NO Percentage of time: Private Placement of Securities [ ] YES [ ] NO Percentage of time: Oil and Gas Syndications(including oil and gas programs, partnerships, and fractional interest syndications) [ ] YES [ ] NO Percentage of time: Real Estate Syndications(including real estate programs, partnerships, and fractional interest syndications) [ ] YES [ ] NO Percentage of time: Other investment vehicles(any business entity or association which uses or contemplates using private investor funds) [ ] YES [ ] NO Percentage of time: Other types of Securities Practice [ ] YES [ ] NO Percentage of time: Provide the following information for securities transactions in which the applicant has provided legal services in the past two years. a. Name of Company/Venture: b. Size of Offering or Syndication: c. Role in Transactions: Feel free to create a table for this information. TLIE Forms Securities Ver. 2 SUPPLEMENTAL CLAIM INFORMATION Applicant's Instructions: This form is to be completed for any attorney associated with the applicant who has been involved in any claim or suit or who is aware of any incident which may give rise to a claim. COMPLETE ONE FORM FOR EACH CLAIM OR INCIDENT. 1. Applicant: 2. Full name of individual(s) of firm involved in the claim: 3. Full name of Claimant: 4. Indicate whether: [ ] Claim/Suit or [ ] Incident (check one) 5. Date of alleged error: 6. Date of Claim: 7. Additional defendants: 8. IF CLOSED: Total Loss Paid Including Deductible: Defense Cost Paid: Indicate whether: [ ] Court judgment or [ ] Out of court settlement (check one) 9. IF PENDING: Claimant's settlement demand? Defendant's offer for settlement? Insurer's loss reserve? Deductible? Is claim in Suit? [ ] Yes [ ] No. If Yes, Amount asked in summons? 10. Name of Insurer: 11. Description of claim: (Provide enough information to allow evaluation.) a.) Alleged act, error omission upon which Claimant bases claim: b.) Description of case and events: c.) Description of the type and extent of injury or damage allegedly sustained: I understand that this information becomes a part of my Professional Liability Insurance Application and is subject to the same warranty and conditions. Signature of Applicant _________________________________ Date _____________ TLIE Forms Claims Ver. 2