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Home > Professional Liability Insurance > Premium Indication Form
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Premium Indication Form


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Select Your Broker *
If you were referred by another lawyer, please provide their name
Firm Information
Firm Name *
Street *
City *
State *
ZIP / Postal Code *
Telephone *
Fax # *
Firm Established
/ /
Website
Contact Information
First Name *
Last Name *
E-Mail Address *
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
Attorney Name *
Year Private Practice Began *
States Admitted *
D/C* *


Hold down the Ctrl Key to make multiple selections.
# Of Hours Worked Per Week For Firm (IC,OC or PT Only) *
Date Joined Firm *
/ /
CLE Hours *
Attorney
Attorney Name
Year Private Practice Began
States Admitted
D/C*


Hold down the Ctrl Key to make multiple selections.
# Of Hours Worked Per Week For Firm (IC,OC or PT Only)
Date Joined Firm
/ /
CLE Hours
Attorney
Attorney Name
Year Private Practice Began
States Admitted
D/C*


Hold down the Ctrl Key to make multiple selections.
# Of Hours Worked Per Week For Firm (IC,OC or PT Only)
Date Joined Firm
/ /
CLE Hours
Attorney
Attorney Name
Year Private Practice Began
States Admitted
D/C*


Hold down the Ctrl Key to make multiple selections.
# Of Hours Worked Per Week For Firm (IC,OC or PT Only)
Date Joined Firm
/ /
CLE Hours
Attorney
Attorney Name
Year Private Practice Began
States Admitted
D/C*


Hold down the Ctrl Key to make multiple selections.
# Of Hours Worked Per Week For Firm (IC,OC or PT Only)
Date Joined Firm
/ /
CLE Hours
Attorney
Attorney Name
Year Private Practice Began
States Admitted
D/C*


Hold down the Ctrl Key to make multiple selections.
# Of Hours Worked Per Week For Firm (IC,OC or PT Only)
Date Joined Firm
/ /
CLE Hours
2. Current Insurance Information
Carrier
Policy Effective Date
/ /
Retroactive Date
/ /
Deductible
Liability Limit
Policy Premium
Provide the number of years the firm has had continuous professional liability insurance coverage
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.
Admiralty/Marine
Anti-Trust Trade Regulation
Arbitration/Mediation
Banking*
Bankruptcy
Bodily Injury/ Defense
BI/PI Plaintiff Non Med Mal
BI/PI Plaintiff Med Mal (see 3B below)
Collections Repossession
Copyright/Patent/TM*
Corporate (General)
Corporate (Formation/Alt)
Corporate (License/Permits)
Corporate (M/A)
Criminal
Domestic Relations
Entertainment
Environmental
ERISA
Est. Plan/Probate/Trust/Wills
Immigration
International Law
Investment Counseling
Labor Relations
Public Utilities
Real Estate - Residential
Real Estate – Commercial
Real Estate – Synd. Development
Real Estate – Title Work
Real Estate – Condo Offering
Securities – Federal*
Securities – State*
Securities – Private Placements*
Securities – Bonds*
Social Security Disability
Tax Preparation
Tax Opinions
Workers Comp/Defense
Workers Comp/Plaintiff
Other (Describe if over 5%)
TOTAL (Most equal 100%)
3B
If you have any BI/PI Plaintiff Med Mal, what is the average case value?
What is the max value?
4.
Does the firm perform class action services? *

If Yes, Defense only?

5.
Fee Suits in past 3 years *
Number of Support Staff *
If Solo, back up attorney?

6.
Is the firm’s docket and calendar control system... *

Does the firm issue engagement letters, declination letters, and disengagement letters on a regular basis? *

In the past 5 years has any insurer declined, canceled, or non-renewed your professional liability coverage? *

Has any attorney in the firm been refused admission to practice, disbarred, suspended, reprimanded, sanctioned or have any disciplinary complaints or ongoing disciplinary investigations? *

During the past 5 years, has any professional liability claim, suit or potential claim been made against any past or present attorney of the firm? *

Are you aware of any act, error or omission that could give rise to a claim, potential claim or incident? *

If Yes to either of the above two questions, please provide details
If you are unable to complete this form. Please click here to download the PDF version.
Indication Form
Submission Validation
Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
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PO Box 849587
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P: 916.853.2130
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