Attorneys Quote

To obtain a free premium estimate for professional liability insurance with no obligation, please complete the information below. An agent will contact you with an estimate based on the information you have provided. All items marked with a * are required to generate an accurate quote. If terms are accepted a completed application with supplements will be required prior to binding coverage.

Completing this form will not guarantee terms, coverages or premiums.

Firm information
* Firm name:
* Address:
   
* Town: * State: * Zip code:
* Contact person:
* Phone:
  Email:
  Fax:
* Firm structure: Individual
Partnership
Professional corp. or assoc.
* Year established:   *   Number of attorneys:

Attorney #1 information
* Name:
* Date of birth:  (mm/dd/yyyy)
* Bar state:
* Year admitted:
* Years in private practice:
* Primary area of practice:
* % billings from primary area of practice: %
* Date joined this firm:  (mm/yyyy)

Attorney #2 information
* Name:
* Date of birth:  (mm/dd/yyyy)
* Bar state:
* Year admitted:
* Years in private practice:
* Primary area of practice:
* % billings from primary area of practice: %
* Date joined this firm:  (mm/yyyy)

Attorney #3 information
* Name:
* Date of birth:  (mm/dd/yyyy)
* Bar state:
* Year admitted:
* Years in private practice:
* Primary area of practice:
* % billings from primary area of practice: %
* Date joined this firm:  (mm/yyyy)

Attorney #4 information
* Name:
* Date of birth:  (mm/dd/yyyy)
* Bar state:
* Year admitted:
* Years in private practice:
* Primary area of practice:
* % billings from primary area of practice: %
* Date joined this firm:  (mm/yyyy)

Attorney #5 information
* Name:
* Date of birth:  (mm/dd/yyyy)
* Bar state:
* Year admitted:
* Years in private practice:
* Primary area of practice:
* % billings from primary area of practice: %
* Date joined this firm:  (mm/yyyy)

Additional firm information
* Number of support staff:
* Number of counsels:
* Do you have any staffed locations
in addition to the one listed above?
* Current insurance carrier:
* Renewal date:  (mm/yyyy)
* Retroactive date:  (mm/yyyy)
* Limits: $
* Deductible: $
* Premium: $
* Desired limits: $
* Desired deductible: $
* Inception date of firm's insurance:  (mm/yyyy)

Claims history
* Please provide the date of
your earliest claims made policy without interruption:		  (mm/yyyy)
* Please list the claim dates, amounts paid, and reserve amounts of
any incidents or losses against your firm in the last 5 years:
 

Docket systems / Internal procedures
* How many independent data controls are kept?
* How many times per month are they cross-checked?
* Do you have a conflict of interest avoidance procedure?
* Do you use client communication letters?
* How many suits for fees have you had
against your own clients in the last two years?

Practice profile
* Please indicate the percentage completed for each category: (Must equal 100%)
Bankruptcy %   Business Formations/Alterations %
Civil Rights/Descrimination %   Collections/Repossessions %
Construction/Building contracts %   Consumer claims %
Copyright/Patent/TM %   Corporate/Commercial litigation %
Criminal %   Insurance Defense/P.I./B.I. %
Domestic relations %   Entertainment %
Environment %   Estates/Trusts/Wills %
Financial institutions/Banking %   Government contracts %
Immigration/Naturalization %   International law %
Labor/Management/Unions %   Local government %
Natural resources %   Plaintiff/P.I./B.I. %
Real Estate - Commercial %   Real Estate - Residential %
Securities/Bonds %   Syndications/Ltd. partnerships %
Taxation %   Workers' compensation - Defendant %
Workers' compensation - Plaintiff %   Other %

Questions or comments

  

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