| Firm Information |
Required
|
|
Required
|
|
Required
|
|
Required
|
|
Required
|
|
Required
|
|
Required
|
|
Optional
|
|
|
/ |
|
/ |
|
|
Optional
|
|
| Contact Information |
Required
|
|
Required
|
|
Required
|
|
| 1. Attorney Schedule |
|
|
Include all attorneys in the firm. Each Attorney must be listed to be considered insured. |
|
|
Use Additional Forms if more then 5 insured’s. *O- Owners, Officers, Directors, Shareholders P- Partners PT- Part Time
IC- Independent Contractor A- Associate Attorney OC- Of Counsel |
| Attorney |
Required
|
|
Required
|
|
Required
|
|
Required
|
Hold down the Ctrl Key to make multiple selections. |
Required
|
|
Required
|
|
|
/ |
|
/ |
|
|
Required
|
|
| Attorney |
Optional
|
|
Optional
|
|
Optional
|
|
Optional
|
Hold down the Ctrl Key to make multiple selections. |
Optional
|
|
Optional
|
|
|
/ |
|
/ |
|
|
Optional
|
|
| Attorney |
Optional
|
|
Optional
|
|
Optional
|
|
Optional
|
Hold down the Ctrl Key to make multiple selections. |
Optional
|
|
Optional
|
|
|
/ |
|
/ |
|
|
Optional
|
|
| Attorney |
Optional
|
|
Optional
|
|
Optional
|
|
Optional
|
Hold down the Ctrl Key to make multiple selections. |
Optional
|
|
Optional
|
|
|
/ |
|
/ |
|
|
Optional
|
|
| Attorney |
Optional
|
|
Optional
|
|
Optional
|
|
Optional
|
Hold down the Ctrl Key to make multiple selections. |
Optional
|
|
Optional
|
|
|
/ |
|
/ |
|
|
Optional
|
|
| Attorney |
Optional
|
|
Optional
|
|
Optional
|
|
Optional
|
Hold down the Ctrl Key to make multiple selections. |
Optional
|
|
Optional
|
|
|
/ |
|
/ |
|
|
Optional
|
|
| 2. Current Insurance Information |
Optional
|
|
Optional
|
|
|
/ |
|
/ |
|
|
Optional
|
|
|
/ |
|
/ |
|
|
Optional
|
|
Optional
|
|
Optional
|
|
Optional
|
|
| 3A. Areas of Practice |
|
|
Total 100% - based on time devoted in each area of specialty during the previous year. Grand Total most
equal 100%. Express percentages in whole numbers next to the type of law practice, not the business of the client represented. |
Optional
|
|
Optional
|
|
Optional
|
|
Optional
|
|
Optional
|
|
Optional
|
|
Optional
|
|
Optional
|
|
Optional
|
|
Optional
|
|
Optional
|
|
Optional
|
|
Optional
|
|
Optional
|
|
Optional
|
|
Optional
|
|
Optional
|
|
Optional
|
|
Optional
|
|
Optional
|
|
Optional
|
|
Optional
|
|
Optional
|
|
Optional
|
|
Optional
|
|
Optional
|
|
Optional
|
|
Optional
|
|
Optional
|
|
Optional
|
|
Optional
|
|
Optional
|
|
Optional
|
|
Optional
|
|
Optional
|
|
Optional
|
|
Optional
|
|
Optional
|
|
Optional
|
|
Optional
|
|
Optional
|
|
| 3B |
Optional
|
|
Optional
|
|
| 4. |
Required
|
|
Optional
|
|
| 5. |
Required
|
|
Required
|
|
Optional
|
|
| 6. |
Required
|
|
Required
|
|
Required
|
|
Required
|
|
Required
|
|
Required
|
|
Optional
|
|
Optional
|
Indication Form |
Submission Validation Required |
|