Lawyers Professional Liability Quick Quote

Firm Name*

Contact Name*

First NameLast Name

Phone Number

Area CodePhone Number

Fax Number

Area CodePhone Number

Email*

Web Site

Address

Street Address

Street Address Line 2

CityState

Zip

If no current insurance check below:

No Current Insurance

Current Professional Liability Carrier

Policy Expiration Date

Retro Prior Acts Date (if any)

Annual Expiring Premium

Expiring Premium Based on How Many Attys

Limits of Liability

Deductible $

Liability Limit Type

Deductible Type

Number of Staff (not including lawyers)

Firm Revenue (last fiscal year)

Administrative Law

Admiralty Law

Adoption Law

Antitrust/Trade Regulation

Arbitration/Mediation

Bankruptcy

Business Trans/Contracts

Civil Rights & Discrimination

Class Action/Mass Torts

Col/Repo-Commercial

Col/Repo-Consumer

Commercial Litigation

Civil Litigation

Construction/Bldg Contracts

Consumer Claims

Corporate Administrative

Corp & Bus Org

Corporate Mergers & Acq

Criminal

Divorce w/Assets < $1M

Divorce w/Assets $1M-$5M

Divorce w/Assets > $5M

Entertainment

Environmental Law

ERISA / Employee Benefits

Financial Institution/Banking

Government Contracts & Claim

Guardianship/Juvenile/Elder

Immigration

Insurance Defense

Intellectual Property

International Law

Labor-Management

Labor-Union/Employee

Land Use & Zoning

Local Government (not bonds)

Natural Resources (Oil & Gas)

Personal Injury - Defense

Personal Injury - Plaintif

Real Estate - Commercial

Real Estate - Residential

Real Estate - Title/Abstracting

Securities or Bonds

Social Security

Taxation

Wills, Trusts, Estate < $1M

Wills, Trusts, Estate $1M-$5M

Wills, Trusts, Estate > $5M

Workers Comp - Defense

Workers Comp - Plaintiff

Other

Total (should total 100)

If Other %, please explain:

Has any lawyer in the law firm been disciplined or denied the right to practice; or is there any such proceeding pending?*

YesNo

What is the total # of incidents/Claims in the past 5 years?

Total Amount paid/reserved for those claims/incidents

Does the firm employ a Conflicts of Interest System

YesNo

Is it computerized?

YesNo

Number of Docket Control Systems:

Computerized?

YesNo

Does your firm use (check all that apply)

Engagement/Fee/RetainerDeclination/Non-EngagementScope of Services, Termination

Total Number of Suits for Fees (including fee proceedings via arbitration/mediation) in the past 2 years:

Does any lawyer have more than 10% ownership in another entity or serve as an officer of another entity?

YesNo

List of Attorneys

*O=Owner, OC=Of Counsel, P=Partner, A=Associate, E=Employee

(if additional space is needed please upload your list below)

Rows	Attorney Name	*Desig.	Date of Hire	Bar Admit Date	Hours /Wk	CLE Current (Y/N)
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5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

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I would also like quotes for:

Employment Practices LiabilityWorkers CompensationBusiness Owners/General Liability

Please note: Premium indications will be provided based on the above information. This form does not guarantee coverage. An insurance APPLICATION must still be completed for a policy to be issued. All premiums are subject to underwriting review of a completed application.

Lawyers Professional Liability Quick Quote

Current Policy Information

Firm Information

Areas of Practice