LAWYERS PROFESSIONAL LIABILITY
PRELIMINARY PREMIUM INDICATION QUESTIONNAIRE
GENERAL INFORMATION
Firm Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date Established
-
Month
-
Day
Year
Date
Phone Number
-
Area Code
Phone Number
Contact Name
First Name
Last Name
Contact Email
*
example@example.com
STAFFING INFORMATION
Number of Lawyers Employed by the Firm
Full Time
Part Time
Of Counsels
5+ Years With Firm
4 Years With Firm
3 Years With Firm
2 Years With Firm
1 Years With Firm
>1 Years With Firm
Number of Attorneys that LEFT in the last 12 months
INSURANCE AND CLAIM HISTORY
Do your firm currently have Lawyers Professional Liability Insurance?
*
Yes
No
Please List Your Current Insurance History Below
*
Current Insurance Information
Carrier
Limits of Liability
Deducitble
Premium
Expiration Date
Retroactive/Prior Acts Date
Please Upload a Copy of Your Current Policy Here
Choose File
Cancel
of
Does your firm have any claims or disciplinary matters in the past 5 years?
*
Yes
No
5-Yr Professional Liability Claim History
*
Please Select Your Desired Limits and Deductible Options
Requested Limits of Liability
$100,000 / $300,000
$250,000 / $500,000
$500,000 / $500,000
$1,000,000 / $1,000,000
$2,000,000 / $2,000,000
$3,000,000 / $3,000,000
$5,000,000 / $5,000,000
+$5,000,000
Requested Deductible
$1,000
$2,500
$5,000
$10,000
$15,000
$25,000
+$25,000
AREA OF PRACTICE
(Percentages must total 100%)
Indicate Current Percentage of Time Devoted to the Following Areas of Practice
*
%
Administrative Law
Admiralty Defense
Admiralty Marine
Adoptions
Arbitration/Mediation
Banking
Bankruptcy
BI/PI Defense
Bonds
Business Transactions
Civil Rights
Civil/General Litigation
Class Action Plaintiff
Collection
Commercial Defense
Commercial Law
Consumer Claims
Construction Law
Contracts
Corporate Formation
Corporate General
Corporate Litigation
Criminal Law
Divorce
Employment Law
Entertainment
Environmental Law
ERISA
Estate Planning
Estate/Trust/Probate
Family Law – (Non-Divorce)
Fiduciary
Foreclosures
Foreign Law
Guardianships
High Profile Divorce or Monied
Immigration/Naturalization
Insurance Defense
International Law
Investment Money Manger
Juvenile
Labor Unions
Labor/Employee
Labor/Management
Landlord Tennant/Leases
Lobbying
Local Government
Medical Malpractice Defense
Medical Malpractice Plaintiff
Mergers & Acquisitions
Municipal Law
Oil & Gas Mining
Oil & Gas Title
Patent, Trademark, Copyright – Filing
Plaintiff BI/PI (Non Product Liability)
Product Liability Plaintiff
Real Estate Closings/General
Real Estate Commercial Title
Real Estate Development
Real Estate Investment Trusts
Real Estate Limited Partnership
Real Estate Residential Title
Real Estate Syndication
Securities
Taxation Opinions
Taxation Preparation
Taxation Representation
Traffic
Wills
Workers Compensation
Other
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