Legal E&O Inquiry Form

LEGAL E&O INQUIRY FORM

This Legal Errors & Omissions Inquiry Form (the "Form") is made and entered into by Applicant Name: and Broker Name: effective as of .

RECITALS

WHEREAS, Applicant seeks information, quotations, or placement assistance in connection with professional liability (Errors & Omissions) insurance for legal services rendered; and

WHEREAS, Broker is authorized by Applicant to inquire of prior and current insurers, claims administrators, and other third parties to obtain insurance policy data, claims history, and underwriting information necessary for evaluating and placing E&O coverage for Applicant; and

WHEREAS, the parties desire to set forth Applicant's representations, authorizations, confidentiality obligations, and limitations of liability in connection with such inquiry and any reliance thereon.

NOW, THEREFORE, in consideration of the mutual covenants contained herein and other good and valuable consideration, the receipt and sufficiency of which are acknowledged, the parties agree as follows:

1. DEFINITIONS

For purposes of this Form: (a) "Applicant" means the party identified as Applicant Name; (b) "Broker" means the party identified as Broker Name; (c) "Policy Data" means the terms, endorsements, limits, retroactive dates, and premium information for insurance policies; and (d) "Claims" means notices, demands, administrative actions, suits, or circumstances that could reasonably give rise to a claim for professional liability.

2. SCOPE OF INQUIRY; AUTHORIZATION

Applicant authorizes Broker, and Broker's authorized representatives, to contact current and former insurers, claims administrators, loss run providers, regulatory authorities, and other third parties to obtain Policy Data and Claims history relating to Applicant. Applicant authorizes any such third party to release Policy Data and Claims information to Broker and to provide copies of policies, endorsements and loss runs.

Applicant acknowledges that Broker may share Policy Data and Claims information with insurers and reinsurers for the purpose of underwriting, quoting, placing, or renewing E&O coverage and that Broker may reasonably rely upon information obtained from third-party sources.

3. APPLICANT REPRESENTATIONS AND WARRANTIES

Applicant represents and warrants that the information provided in this Form is true, complete and correct as of the Effective Date, that Applicant will promptly notify Broker of any material change in circumstances, and that Applicant has the authority to provide authorizations and releases contained herein.

4. INFORMATION TO BE PROVIDED BY APPLICANT

Individual Attorney Law Firm (LLP, PC, etc.) Corporation

5. CURRENT AND PRIOR INSURANCE

6. CLAIMS AND MATTERS

Have any claims, suits, arbitration proceedings, or circumstances been asserted against Applicant or reported to any insurer within the last ten (10) years? Yes    No

7. CONFIDENTIALITY; USE OF INFORMATION

All Policy Data and Claims information obtained by Broker pursuant to this Form shall be treated as confidential by Broker and shall only be used for underwriting, placement, renewal and related administrative purposes. Broker may disclose such information to insurers, reinsurers, legal counsel, auditors and prospective insurers on a need-to-know basis. Nothing in this Form restricts Broker's ability to disclose information required by law or regulatory authorities.

8. INDEMNIFICATION; RELIANCE

Applicant agrees to indemnify, defend and hold harmless Broker and its affiliates, agents and employees from and against any losses, liabilities, claims, damages, costs and expenses (including reasonable attorneys' fees) arising out of Applicant's breach of any representation, warranty or obligation under this Form or arising from Applicant's failure to disclose material information requested by Broker.

Broker may reasonably rely upon information provided by Applicant and upon information obtained from third parties. Broker shall have no duty to verify the accuracy of information provided by Applicant or third parties and shall not be responsible for underwriting, coverage determinations, or claim handling performed by insurers.

9. LIMITATION OF LIABILITY

EXCEPT FOR LIABILITY ARISING FROM BROKER'S WILLFUL MISCONDUCT OR GROSS NEGLIGENCE, BROKER'S AGGREGATE LIABILITY FOR ANY CLAIMS ARISING OUT OF OR RELATING TO THIS FORM SHALL BE LIMITED TO THE AMOUNT OF FEES PAID BY APPLICANT TO BROKER FOR SERVICES RELATING TO THE SPECIFIC INQUIRY GIVING RISE TO SUCH LIABILITY. IN NO EVENT SHALL BROKER BE LIABLE FOR INDIRECT, SPECIAL, INCIDENTAL OR CONSEQUENTIAL DAMAGES.

10. NOTICES

All notices and communications required or permitted under this Form shall be in writing and shall be delivered to the addresses provided below. Notice shall be deemed given when delivered in person, when sent by certified mail return receipt requested, or when transmitted by electronic mail with confirmation of receipt.

11. AMENDMENT; WAIVER; COUNTERPARTS

This Form may be amended or modified only by a writing signed by both parties. No waiver of any provision shall be effective unless in writing and signed by the waiving party. This Form may be executed in counterparts and by electronic signature and each counterpart shall be an original and together shall constitute one instrument.

12. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Form shall be governed by and construed in accordance with the laws of the jurisdiction in which Applicant principally practices, without regard to conflict of law principles. This Form constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior communications and agreements. If any provision of this Form is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.

The parties acknowledge that they have read and understand this Form, that they have had the opportunity to obtain independent legal counsel, and that they execute this Form voluntarily.

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