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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.

Firm Information
Firm Name
Required
Street
Required
City
Required
State
Required
ZIP / Postal Code
Required
Telephone
Required
Fax #
Required
Firm Established
Optional
/ /
Website
Optional
Contact Information
First Name
Required
Last Name
Required
E-Mail Address
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
Attorney Name
Required
Year Private Practice Began
Required
States Admitted
Required
D/C*
Required


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


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


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


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


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


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

If Yes, Defense only?
Optional

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

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

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

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

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

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?
Required

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

If Yes to either of the above two questions, please provide details
Optional
Submission Validation
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Important Notice
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