Lawyers Professional Liability Application
Please complete the application below. To speak with a licensed agent please call 877-831-9462
Firm Name
*
Contact Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone number
*
Do you consent to receive text messages regarding your inquiry?
Yes
No
E-mail
*
Website
Comments/Special Requests
Do you have current Insurance Coverage. If yes please complete the section below.
*
Yes
No
Attorney Information
*
In the past 5 years, has an attorney had coverage declined, cancelled or non renewed, been subject to reprimand, disciplinary action, had any claims or is anyone aware of any circumstances, incidents errors, etc that may result in a claim?
Yes
No
If you checked yes above please provide details in this box
Areas of Practice: Please note percentage of work done in each area (*=We may need additional information to provide a quote if you are working in these areas)
Rows
%
Administrative Law
Adoption Law
Arbitration/Mediation
Bankruptcy
Business Transactions/Contracts
Civil Rights/Discrimination
Collection/Repossession
Commercial Lit-Plaintiff
Commercial Lit -Defense
Construction/Building Contracts
Consumer Claims
Corporate/Business Administration
Corporate Mergers/Acquisitions
Criminal
Divorce w/ Assets <$1M
Divorce w/ Assets $1-$5M
Divorce w/ Assets >$5M
Enviromental Law
Entertainment
ERISA/Employee Benefits
Guardianship/Juvenile
Immigration/Naturalization
Insurance Defense
Intellectual Property*
International Law
Labor-Management
Labor-Union/Employee
Mass Torts/Class Action*
Medical Malpractice*
Natural Resources (Oil and Gas)
Personal Injury-Plaintiff
Personal Injury-Defense
Real Estate-Commercial
Real Estate-Residential
Real Estate-Title/Abstacting
Securities*
Social Security
Taxation
Workers' Comp-Plaintiff
Workers' Comp-Defense
Wills,Trusts, Estates>$1M
Wills, Trusts, Estates $1-$5M
Wills, Trusts, Estates>$5M
Other (please describe and include %)
Other (please describe and include %)
Additional Comments
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