PREMIUM INDICATION FORM
QUOTE REQUEST

FREE PRICE ESTIMATE
(This is NOT an application for coverage)
Fill out the form below and click on the "Submit" button to receive your no cost - no obligation price estimate on your attorney professional liability coverage.

Name of Firm
Year Firm Est.
Physical Address
Mailing Address
City
 State
City
 State
Zip Code
- 
Zip Code
- 
County
County
     
Business Phone
 Is Firm:
Business Fax
  Sole Practitioner  Partnership
Contact Person
  Prof. Corporation  Other :
Email Address
  
Website Address
  
 
2. Provide info on all attorneys that render service on behalf of the firm.
NAME OF ATTORNEY(S)
POSITION
 States
Licensed
to
Practice
Date Admitted
to Bar:
MONTH / YEAR
 Date Joined Firm:
MONTH/DAY/YEAR		 # of hours worked
per week:
 
 
 
 
 

 
3. Is the firm currently insured?  Yes No
If YES, please check if either FULL PRIOR ACTS
or enter PRIOR ACTS EXCLUSION DATE		 FULL PRIOR ACTS
  OR ENTER PRIOR ACTS EXCLUSION DATE
List past 5 years of insurance history below
Insurance Company Limits of Liability Deductible Amount From To

4. Please select the limits and deductible desired:
Limits: Per Claim / Policy Aggregate
   Deductible
Please select any additional amounts below (if applicable)
   
 
     
 
Other:
   $
 

Please select any additional amounts below (if applicable)
 
 
Other please specify: 
   $
 
 
 
 
  5.  Sole practitioners must provide name of back-up attorney: 
  6.  Number of support staff:   If number is "0" please enter NA
Paralegal / Law Clerk    Secretarial        Other 
  7.  Is the firm's date/docket control system computerized? Yes No
  8.
 		  Does the firm have a conflict of interest avoidance system? Yes No
  9.  Indicate percentage of time the firm utilizes:   If number is "0" please enter NA
a) An engagement letter/contract when accepting a new client?
% 
b) A non-engagement letter when declining to represent?
% 
c) A disengagement letter when concluding a matter?
% 
     
  10.
  How many suits for collections of attorney's fees have been filed by the firm in the last 24 months?
If number is "0" please enter NA
 
Disposition of fee suits:  If number is "0" please enter NA
# Open
# Closed in favor of firm
# Closed in favor of client
11.
 Has any attorney been the subject of a reprimand, disciplinary action or grievance in the past five years? Yes No
 
Date of action(s) / Complaint
Final disposition of matter(s)
12.
 Does any attorney in this firm serve as a director, officer, trustee or partner of, or own any equity interest in any client of the firm?  If yes, provide details in the text box below. Yes No
 
   
13.
  Has any attorney ever had malpractice coverage cancelled or non renewed?
 If yes, provide details in the text box below. 		Yes No
 
   
14.
  Any attorney had a claim, suit or incident in the past five years?
 If yes, provide details in the text box below.		 Yes No
 
 
   
 
15. Please indicate percentage of time devoted to the following areas of practice: 

Admirality / Marine - Defense %    LITIGATION  
Admirality / Marine - Plaintiff %        Class Action - Defense %
Anti-Trust / Trade Regulation %        Class Action - Plaintiff %
Arbitrator / Mediator %        General Commercial - Defense %
Appellate Law %        General Commercial - Plaintiff %
Banking / Regulatory %  
     Insurance Defense
 %
Bankruptcy %        Personal Injury / Prop Damage - Defense %
           Personal Injury / Prop Damage - Plaintiff %
BUSINESS TRANSACTIONS/ CORPORATE LAW
         Workers' Compensation - Defense %
      Administrative %        Workers' Compensation - Plaintiff %
      Formation of Entities %      
      General Contract Negotiation %   Local Government / Municipal (not bonds)
      Mergers & Acquisitions %   Natural Resources / Oil & Gas 
      Public Utilities 
Civil Rights / Discrimination %      
Collections %    REAL ESTATE  
Construction (Building Contracts) %        Real Estate - Commercial %
Consumer Claims  %        Real Estate - Development %
Criminal  %        Real Estate - Foreclosure %
Entertainment %        Real Estate - Residential %
Environmental Law %        Real Estate - Title Work %
ERISA / Pension / Employee Benefits  %      
      School Law %
 FAMILY LAW     Securities (SEC, Blue Sky, Bonds) %
     Adoption %      
     Divorce - marital assets < $500,000 %    TAXATION  
     Divorce - marital assets > $500,000  %        Business % 
     Elder Law  %        Individual %
     Guardianship / Juvenile  %        Tax Litigation %
     Social Security  %        Opinions % 
       
Govt. Contracts / Claims %    WILLS, ESTATE, TRUST, PROBATE & PLANNING  
Healthcare - Regulatory Compliance  %         For Assets < $500,000 % 
Immigration / Naturalization  %         For Assets > $500,000 %  
Intellectual Property %      
International Law %   Other (please describe):  
Labor / Employment - Management %   %  
Labor / Employment - Employee or Union %   Total 100%