Firm Information
State *
Firm Established
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Contact Information
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
D/C* *
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Date Joined Firm *
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Attorney
D/C*
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Date Joined Firm
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Attorney
D/C*
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Date Joined Firm
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Attorney
D/C*
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Date Joined Firm
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Attorney
D/C*
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Date Joined Firm
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Attorney
D/C*
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Date Joined Firm
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2. Current Insurance Information
Policy Effective Date
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Retroactive Date
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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.
3B
4.
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6.
If Yes to either of the above two questions, please provide details
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