First Indemnity Insurance Agency, Inc.
87 Oxford Street The Equitable Cooperative Bank Building Lynn, MA 01901
Phone: 781-581-2500 Fax: 781-595-2293

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I. General Information

(a)

Full name of Applicant

(b)

Principal business premises address

Street

Suite/Apartment Number

Zip

City

County

State

(c)

Name of contact person

Email address

(d)

Phone Number

Fax number

(e)

Website address

(f)

Date firm was established

(g)

Business is a

Is the Applicant a sole practitioner?

Yes No

Is there a lawyer that will be responsible for Applicant’s practice if the Applicant is unable to work for an extended period of time?

Yes No

Please provide the following:

Name of back-up lawyer

Address

Phone

Fax

List the names of all predecessor firms of the Applicant. A "Predecessor Firm" is any legal entity which was engaged in the practice of law to whose financial assets and liabilities the Applicant is the majority successor in interest.

	Name of Predecessor Firm	Date Established	Date Dissolved	Did Firm Maintain Coverage?	Extended Reporting Endorsement Purchased (Tail Coverage)?	Requesting Coverage For Predecessor Firm?
#{{$index + 1}}				Yes No	Yes No	Yes No

Name of Predecessor Firm	Date Established	Date Dissolved	Did Firm Maintain Coverage?	Extended Reporting Endorsement Purchased (Tail Coverage)?	Requesting Coverage For Predecessor Firm?
{{Predecessors_Info.Predecessor_Firm_Name}}	{{Predecessors_Info.Established_Date=="Invalid date"?'':Predecessors_Info.Established_Date}}	{{Predecessors_Info.Dissolved_Date}}	{{Predecessors_Info.Maintain_Coverage}}	{{Predecessors_Info.Tail_Coverage}}	{{Predecessors_Info.Coverage_Req_Predecessor_Firm}}

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I. General Information

Confirmation