Lawyers Professional Liability Insurance Policy Premium Indicator

Applicant Firm: 
Date Established:
Contact Information
Street Address
Address 2
City
County:
State
Postal Code
Contact Person: 
E-mail Address 
Telephone: 
Fax:
Website:
1. Areas of Practice
Admiralty/Marine
Arbitration/Mediation
Banking/Financial
Business Transaction/Commercial Law
Civil/Commercial Litigation Defense
Civil Rights/Discrimination
Bankruptcy
Collection
Construction
Consumer Claims
Corporate Business Organization
Criminal
Corporate Business Organization
Family Law/Divorce where value of marital estate is less than $1,000,000
Family Law/Divorce where value of marital estate is greater than $1,000,000
Family Law/No Divorce
Environmental Law
Government Contracts/Claims
Immigration/Naturalization
Intellectual Property (Patent, Trademark, Copyright)
International Law
Labor-Union Representative
Labor-Management Representative
Local Government
Natural Resources/Oil and Gas
Personal Injury/Property Damage-Defense
Personal Injury/Property Damage-Plaintiff
Real Estate - Commercial
Real Estate - Residential
Securities (SEC)
Taxation
Estate Planning & Admin where estate is less than $1,000,000
Estate Planning & Admin where estate is greater than $1,000,000
Wills & Probate
Workers' Comp. Defense
Workers' Comp. Plaintiff
Other (please describe):

TOTAL Must Equal 100%

Sample of firm letterhead
Unaltered copy of the current policy, if applicable
Signature:
Date: (mm/dd/yyyy)
Attorney/Staff Details (attach separate sheet if necessary)
Attorney 1 Details
Attorney's Name
Date Joined Firm
Bar Admit Date
State Bar Number
Relation to firm? (use code shown below)
Weekly Hours
Attorney 2 Details
Attorney's Name
Date Joined Firm
Bar Admit Date
State Bar Number
Relation to firm? (use code shown below)
Weekly Hours
Attorney 3 Details
Attorney's Name
Date Joined Firm
Bar Admit Date
State Bar Number
Relation to firm? (use code shown below)
Weekly Hours

Codes: [P] Partner [S] Solo [E] Employed Attorney [IC] Ind. Contractor [OC] Of Counsel

b. Total Number of Support Staff
3. Risk Management
Client Communication:
Calendar/Docket Control:
Conflict of Interest:
Comments
4. Firm's Revenue (projected or prior fiscal year):
5. Fee Suits (filed against clients for unpaid legal fees in past 12 months)
6. Outside Interest Is any attorney noted above an officer, director, shareholder, member, have equity interest in or exercise fiduciary control of a client of the firm?
7. Current Insurance
Are you currently insured for lawyers professional liability insurance?
Carrier:
Expiration Date: (mm/dd/yyyy)
Retroactive Date: (mm/dd/yyyy)
Limit: $
Deductible: $
Premium: $
Firm Size:
If applicable, upload current insurance information rather than writing in
8. Claims/Incidents Information
a. Has any professional liability insurance for the applicant, or any member of the applicant firm ever been declined or cancelled, refused to be renewed or accepted only on special terms?
b. Has any professional liability claim or suit been made in the past seven (7) years against the firm or its predecessor firm(s) 
TOTAL NO. OF CLAIMS
c. 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)? 
TOTAL NO. OF INCIDENTS
If "Yes", to a. or b., please attach a copy of the Claim Supplement you completed for the current Insurer and for the current insurer or provide an addendum with details of the firms claim history.
d. Has any current or former member of the firm ever been the subject of a reprimand or disciplinary action or refused admission 

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