| Firm Information |
| Firm Name
Required
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| Street
Required
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| City
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| State
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| ZIP / Postal Code
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| Telephone
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| Fax #
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| Firm Established
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| Website
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| Contact Information |
| First Name
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| Last Name
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| E-Mail Address
Required
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| 1. Attorney Schedule |
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Include all attorneys in the firm. Each Attorney must be listed to be considered insured. |
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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
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| Year Private Practice Began
Required
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| States Admitted
Required
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| D/C*
Required
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Hold down the Ctrl Key to make multiple selections. |
| # Of Hours Worked Per Week For Firm (IC,OC or PT Only)
Required
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| Date Joined Firm
Required
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| CLE Hours
Required
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| Attorney |
| Attorney Name
Optional
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| Year Private Practice Began
Optional
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| States Admitted
Optional
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| D/C*
Optional
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Hold down the Ctrl Key to make multiple selections. |
| # Of Hours Worked Per Week For Firm (IC,OC or PT Only)
Optional
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| Date Joined Firm
Optional
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| CLE Hours
Optional
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| Attorney |
| Attorney Name
Optional
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| Year Private Practice Began
Optional
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| States Admitted
Optional
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| D/C*
Optional
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Hold down the Ctrl Key to make multiple selections. |
| # Of Hours Worked Per Week For Firm (IC,OC or PT Only)
Optional
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| Date Joined Firm
Optional
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| CLE Hours
Optional
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| Attorney |
| Attorney Name
Optional
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| Year Private Practice Began
Optional
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| States Admitted
Optional
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| D/C*
Optional
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Hold down the Ctrl Key to make multiple selections. |
| # Of Hours Worked Per Week For Firm (IC,OC or PT Only)
Optional
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| Date Joined Firm
Optional
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| CLE Hours
Optional
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| Attorney |
| Attorney Name
Optional
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| Year Private Practice Began
Optional
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| States Admitted
Optional
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| D/C*
Optional
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Hold down the Ctrl Key to make multiple selections. |
| # Of Hours Worked Per Week For Firm (IC,OC or PT Only)
Optional
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| Date Joined Firm
Optional
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| CLE Hours
Optional
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| Attorney |
| Attorney Name
Optional
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| Year Private Practice Began
Optional
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| States Admitted
Optional
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| D/C*
Optional
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Hold down the Ctrl Key to make multiple selections. |
| # Of Hours Worked Per Week For Firm (IC,OC or PT Only)
Optional
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| Date Joined Firm
Optional
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| CLE Hours
Optional
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| 2. Current Insurance Information |
| Carrier
Optional
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| Policy Effective Date
Optional
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| Retroactive Date
Optional
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| Deductible
Optional
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| Liability Limit
Optional
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| Policy Premium
Optional
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| Provide the number of years the firm has had continuous professional liability insurance coverage
Optional
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| 3A. Areas of Practice |
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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
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| Anti-Trust Trade Regulation
Optional
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| Arbitration/Mediation
Optional
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| Banking*
Optional
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| Bankruptcy
Optional
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| Bodily Injury/ Defense
Optional
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| BI/PI Plaintiff Non Med Mal
Optional
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| BI/PI Plaintiff Med Mal (see 3B below)
Optional
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| Collections Repossession
Optional
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| Copyright/Patent/TM*
Optional
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| Corporate (General)
Optional
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| Corporate (Formation/Alt)
Optional
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| Corporate (License/Permits)
Optional
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| Corporate (M/A)
Optional
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| Criminal
Optional
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| Domestic Relations
Optional
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| Entertainment
Optional
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| Environmental
Optional
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| ERISA
Optional
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| Est. Plan/Probate/Trust/Wills
Optional
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| Immigration
Optional
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| International Law
Optional
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| Investment Counseling
Optional
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| Labor Relations
Optional
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| Public Utilities
Optional
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| Real Estate - Residential
Optional
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| Real Estate – Commercial
Optional
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| Real Estate – Synd. Development
Optional
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| Real Estate – Title Work
Optional
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| Real Estate – Condo Offering
Optional
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| Securities – Federal*
Optional
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| Securities – State*
Optional
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| Securities – Private Placements*
Optional
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| Securities – Bonds*
Optional
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| Social Security Disability
Optional
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| Tax Preparation
Optional
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| Tax Opinions
Optional
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| Workers Comp/Defense
Optional
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| Workers Comp/Plaintiff
Optional
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| Other (Describe if over 5%)
Optional
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| TOTAL (Most equal 100%)
Optional
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| 3B |
| If you have any BI/PI Plaintiff Med Mal, what is the average case value?
Optional
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| What is the max value?
Optional
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| 4. |
| Does the firm perform class action services?
Required
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| If Yes, Defense only?
Optional
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| 5. |
| Fee Suits in past 3 years
Required
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| Number of Support Staff
Required
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| If Solo, back up attorney?
Optional
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| 6. |
| Is the firm’s docket and calendar control system...
Required
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| Does the firm issue engagement letters, declination letters, and disengagement letters on a regular basis?
Required
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| In the past 5 years has any insurer declined, canceled, or non-renewed your professional liability coverage?
Required
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| 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
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| 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
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| Are you aware of any act, error or omission that could give rise to a claim, potential claim or incident?
Required
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| If Yes to either of the above two questions, please provide details
Optional
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| If you are unable to complete this form. Please click here to download the PDF version.
Optional
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Indication Form |
Submission Validation Required |
Enter the Validation Code from above.
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