SUPPLEMENT
2
FINANCIAL INSTITUTIONS
FULL NAME OF APPLICANT
THE TERMS "INSTITUTION" OR "FINANCIAL INSTITUTION" INCLUDES ANY SAVINGS & LOAN, BANK, CREDIT UNION, SAVINGS ASSOCIATION, BUILDING & LOAN ASSOCIATION; OR SERVICE COMPANY, SUBSIDIARY CORPORATION OR HOLDING COMPANY OF THE AFOREMENTIONED
SECTION A:
This supplement is to be completed by all applicants for Lawyers Professional Liability Insurance, when in the last 5 years, any lawyer associated with the applicant firm and/or its predecessors has provided legal services for your firm's financial institution or financial institution regulatory authority clients.
1.
What percentage of your services are for your firm's financial institution clients?
%
2.
Of the percentage listed above, what percentage of these services include:
A.
Residential loan documentation, residential real estate closings/foreclosures, or title work
%
B.
Commercial loan documentation, commercial real estate closings/foreclosures, bankruptcy, collectionor trust work
%
C.
Financial/investment advisory services
(Please note that such activities are not covered under the policy for which you are applying)
%
D.
Services other than A., B. and C. above
%
Complete Section B on page 2.2 if either questions 3, 4 or 5 are answered "Yes."
3.
Have any lawyers performed services for your firm's financial institution clients other than those listed below?
Yes
No
Bankruptcy
Collection
Loan documentation
Loan Workout
Real estate closings
Real estate foreclosures
Title work/conveyances
Trust work
4.
Has any lawyer:
A.
Had any financial control over or equity interest in a financial institution?
Yes
No
B.
Acted as director, officer, general counsel or committee member for a financial institution?
Yes
No
C.
Been involved with the initial formation of or provided any securities services for a financial institution?
Yes
No
5.
Are any of your firm's financial institution clients uninsured by a government agency such as the FDIC, or NCUA?
Yes
No
SECTION B:
Complete only if you have answered yes to any question numbered 3 through 5 of Section A. Attach additional sheets as needed.
Financial Institution and location
Is the institution insured by any government agency such as FDIC or NCUA?
Is any lawyer involved with the approval of loans?
Check any if applicable:
Name:
City/State :
Yes
No
Yes
No
Equity interest in this financial institution. If yes, give full particulars on a separate addendum.
Initial formation or securities services were provided for this financial institution. Complete Supplement 3.
Check any of the following positions held:
If the Financial Institution has been taken over by a regulatory agency, check if services were provided.
NO POSITION HELD
DIRECTOR
OFFICER
AUDIT COMMITTEE
LOAN COMMITTEE
EXECUTIVE COMMITTEE
GENERAL COUNSEL-List services below
OTHER - List service below
Prior to takeover
After takeover
Both apply
Not applicable
Describe services provided during each time period:
List services provided other than in Question 3 of Section A:
Financial Institution and location
Is the institution insured by any government agency such as FDIC or NCUA?
Is any lawyer involved with the approval of loans?
Check any if applicable:
Name:
City/State :
Yes
No
Yes
No
Equity interest in this financial institution. If yes, give full particulars on a separate addendum.
Initial formation or securities services were provided for this financial institution. Complete Supplement 3.
Check any of the following positions held:
If the Financial Institution has been taken over by a regulatory agency, check if services were provided.
NO POSITION HELD
DIRECTOR
OFFICER
AUDIT COMMITTEE
LOAN COMMITTEE
EXECUTIVE COMMITTEE
GENERAL COUNSEL-List services below
OTHER - List service below
Prior to takeover
After takeover
Both apply
Not applicable
Describe services provided during each time period:
List services provided other than in Question 3 of Section A:
Financial Institution and location
Is the institution insured by any government agency such as FDIC or NCUA?
Is any lawyer involved with the approval of loans?
Check any if applicable:
Name:
City/State :
Yes
No
Yes
No
Equity interest in this financial institution. If yes, give full particulars on a separate addendum.
Initial formation or securities services were provided for this financial institution. Complete Supplement 3.
Check any of the following positions held:
If the Financial Institution has been taken over by a regulatory agency, check if services were provided.
NO POSITION HELD
DIRECTOR
OFFICER
AUDIT COMMITTEE
LOAN COMMITTEE
EXECUTIVE COMMITTEE
GENERAL COUNSEL-List services below
OTHER - List service below
Prior to takeover
After takeover
Both apply
Not applicable
Describe services provided during each time period:
List services provided other than in Question 3 of Section A:
Applicant hereby warrants that the statements set forth herein are true, complete and accurate and that there has been no attempt at suppression or misstatement of any material facts which are known, or should be known. Applicant agrees that this Supplemental Application shall become the basis for any coverage and part of any policy that is issued by the Company.
Date:
Signature:
Title: