FIREARM LEGAL EXPENSE INSURANCE APPLICATION
 
NOTICE: THIS IS A CLAIMS-MADE FORM: EXCEPT TO SUCH EXTENT AS MAY OTHERWISE BE PROVIDED HEREIN, THE COVERAGE OF THIS POLICY IS LIMITED TO LIABILITY FOR ONLY THOSE CLAIMS THAT ARE FIRST MADE AGAINST THE INSURED AND REPORTED IN WRITING TO THE COMPANY WHILE THE POLICY IS IN FULL FORCE. PLEASE REVIEW THE POLICY CAREFULLY. COVERAGE IS WRITTEN ON A SURPLUS LINES BASIS THROUGH CERTAIN UNDERWRITERS AT LLOYDS, LONDON.
* denotes required fields
PLEASE SELECT YOUR PLAN
INSURANCE POLICY LIMITS
Criminal Defense
     Legal Expense Reimbursement
     Total Criminal Aggregate 		 
$25,000
$25,000
  
$50,000
$50,000
  
$75,000
$75,000
  
$150,000
$150,000
  
$250,000
$250,000
Civil Actions
     Legal Defense
     Damages, Awards & Judgments
     Total Civil Action Aggregate 		 
$50,000
$50,000
$50,000
  
$100,000
$100,000
$100,000
  
$300,000
$300,000
$300,000
  
$500,000
$500,000
$500,000
  
$1,000,000
$1,000,000
$1,000,000
Firearm Theft Civil Liability $50,000
$100,000
$300,000
$500,000
$1,000,000
Compensation While in Court (Per Day) N/A
Up to $250
Up to $250
Up to $350
Up to $500
Legal Consultation Hotline (Per Year) Max 2 hours
Max 2 hours
Max 2 hours
Max 2 hours
Max 5 hours
FULL AMOUNT DUE*: $135.00
$175.00
$215.00
$325.00
$425.00
*Rates shown include all applicable premiums, taxes, and fees.

* First Name:   Middle Initial: 
* Last Name:  
* Street Address:  
* City:   * State:   * Zip:  
* Phone:     Fax  
* Email:     
* Date of Birth:    * Gender:     
* Preferred Correspondence Method: 
*B. Are you a member of any hunting/sportsmen clubs or firearm-related Associations?
*      If "Yes", please list:
     
*C. Have you ever been the subject of a lawsuit, criminal investigation, civil proceeding or other legal action due to the use of a firearm?
*      If "Yes", please provide details:
     
*D. Do you currently have, or have applied for licenses or permits to own and carry a firearm under Federal, State and local law, regulations, ordinances and rules?
*      If "Yes", please list State(s) in which you hold or have applied for such licenses or permits:
     
*E. What is the insured's profession?
     
 
   

* 
THE APPLICANT WARRANTS THAT THE STATEMENTS AND RESPONSES TO THE QUESTIONS ON THIS APPLICATION ARE TRUE AND COMPLETE.  THIS APPLICATION DOES NOT BIND THE APPLICANT OR THE COMPANY, NOR DOES IT OBLIGATE THE COMPANY TO ISSUE A POLICY.  SUCH POLICY MAY BE CANCELLED BY THE COMPANY FROM INCEPTION UPON DISCOVERY THAT THE POLICY WAS OBTAINED THROUGH A FRAUDULENT STATEMENT, OMISSION, OR CONCEALMENT OF THE FACTS MATERIAL TO THE ACCEPTANCE OF THE RISK OR HAZARD ASSUMED.