Attorney Deletion Form

Attorney Deletion
Form
Applicant’s Instructions: (Please type or print)
•
Within 30 days of departure, this form must be completed, signed and dated by the Insured Designee,
for each departing attorney.
•
Please fax this form to (314) 821-0534 or email to [email protected]
Firm Name: ___________________________________________________ Policy #: ____________________
1.
Name of departing attorney: ____________________________________________________________
2. Last date of employment with firm: ______________________________________________________
3. Is the departing attorney:
retiring / ceasing private practice?
deceased?
leaving to join another law firm?
leaving to practice on his/her own?
4. Please provide the following information so that we may contact the departing attorney regarding
his/her insurance coverage:
Forwarding Address: __________________________________________________________________
___________________________________________________________________________________
Phone: (_______) ___________________ Email: ___________________________________________
Signature of Insured Designee: ________________________________________________________________
Email Address: _____________________________________________________________________________
Date: ___________________________________________
Important Notice: The departing attorney has the option to purchase Extended Reporting Coverage or
may be eligible for free unlimited Extended Reporting Coverage. To obtain a quote for such coverage,
please complete the Extended Reporting Coverage Form (TBP-44).
Form TBP-36 (2013)