12. Indicate the percentage of time (in total working hours) for each of the following areas of practice: (Must equal 100%)
The undersigned is authorized to sign this application on behalf of all persons in the Firm to be insured and declares to the best of his/her knowledge and belief that the information provided in this application, and attachments, is true and no material facts have been misstated or withheld. The information provided in this application shall be the basis of the policy of insurance and deemed incorporated therein.
The applicant understands that any misrepresentation or false statement on this application or attachments may result in loss of coverage under any policy issued by Lawyers Mutual Insurance Company of Kentucky. Signing this application does not bind the Firm or Lawyers Mutual Insurance Company of Kentucky to issue a policy of insurance.
In accordance with KRS 304.47-030, Lawyers Mutual Insurance Company of Kentucky must give the Firm the following notice in your application for insurance. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.