LAW FIRM
PREMIUM INDICATION
Firm Name
*
Contact Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
*
E-mail
*
example@example.com
# of Employees
*
Do not include attorneys
Attorneys
*
INSURANCE and MANAGEMENT INFORMATION
Do you currently purchase Lawyers' Professional Liability Coverage?
*
Yes
No
Requested Liability Limit:
$250,000
$500,000
$1,000,000
$2,000,000
$3,000,000
$5,000,000
Requested Deductible:
$1,000
$2,500
$5,000
$10,000
$25,000
Policy Information
*
Current Policy Prior Acts Date
*
-
Month
-
Day
Year
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Do you use Legal Practice Management Software?
*
Yes
No
Which Practice Management Software does your firm use?
Have you reported any claims or disciplinary matters in the past 5 year?
*
Yes
No
5-Year Professional Liability Claim History:
AREAS OF PRACTICE
Based on annual gross revenues.
Percentage
Admiralty Defense
Admiralty Plaintiff
Banking
Bankruptcy
Business Organization
Buiness Trans or Comm
Civil Litigation Defense
Civil Litigation Plaintiff
Collection
Construction
Criminal
Family
Government
Immigration
Intellectual Property
Labor
Based on annual gross revenues.
Percentage
Mass Tort or Class Action Plaintiff
Medical Malpractice Plaintiff
Natural Resources
Personal Injury Defense
Personal Injury Plaintiff
Real Estate - Commercial
Real Estate - Residential
SEC Securities
Wills, Trust, Estates (<$5M)
Wills, Trust, Estates (>$5M)
Workers Comp Defense
Workers Comp Plaintiff
Other
Total Percent
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Annual gross billings:
We are also interested in:
Cyber Liability
Commercial Property/General Liability
Workers Compensation
Crime Coverage
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