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Professional Liability Quote Request Form

NOTE: This form is for estimating purposes only. Coverage may be bound only upon submission and acceptance of a completed new business application.

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1. Areas of Practice

Express percentages of time devoted (billable hours) in each area during the previous year. Indicate percentage in whole numbers next to the type of law practiced, not the business of the client represented. If a new firm, projections are acceptable.

































TOTAL Must Equal 100%

*Request Intellectual Property and/or Securities Supplemental Application(s) from the Agent.

2. Attorney/Staff Information

a. Attorneys

Attorney's Name Date Began Practice Date Joined Firm Relation to Firm Number of Weekly Hours

3. Risk Management

Please indicate which of the following are utilized, or expect to be utilized: (check all that apply)

Client Communication:



Calendar/Docket Control:



Conflict of Interest:



4. Firm's Revenue:
5. Current Insurance:
6. Claims/Incidents Information:

a. Has any professional liability claim or suit been made in the past seven (7) years against the firm or its predecessor firm(s) or any current or former member of the firm or its predecessor firm(s)?



b. After inquiry, does any firm member know of any circumstance, situation, act, error or omission that could result in a professional liability claim or suit against the firm or its predecessor firm(s) or any of the current or former members of the firm or its predecessor firm(s)?



c. Has any current or former member of the firm ever been the subject of a reprimand or disciplinary action or refused admission to practice, disbarred, suspended, fined or held in contempt by any court, state or local bar association, administrative agency or regulatory body?








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