Attorney Deletion Form

Attorney Deletion
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 #: ____________________
Name of departing attorney: ____________________________________________________________
2. Last date of employment with firm: ______________________________________________________
3. Is the departing attorney:
retiring / ceasing private practice?
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)