Lawyers Insurance Premium Indication Request

Please provide me with your most competitive NO OBLIGATION premium estimate for professional liability coverage

Firm

Contact

Address

City

County

State

Zip

Phone

Fax

Email

Staff List (Designations: O=Owner, P=Partner, A=Associate, IC=Independent Contractor, OC=Of Counsel, PA=Patent Agent)

Are engagement letters or retainer agreements, that establish the scope of your firm's representation, required to be sent to all new clients?
yesno

Have you ever sued a client (past or present) for uncollected fees?
yesno

Has any member of your firm handled class action or mass tort litigation in the past 5 years?
yesno

Has any member of your firm been disbarred or been the subject of a disciplinary proceeding?
yesno

Area of Practice - What percentage of gross billings are earned from the following (Total Must Equal 100%):

  • Arbitration / Mediation
  • Administrative law
  • Admiralty / Maritime
  • Bankruptcy
  • Collection/Repossessions
  • Commercial Litigation
  • Criminal law
  • Domestic Relations
  • Insurance Defense
  • Personal BI/PD Defense
  • Workers Compensation Defense
  • Anti-Trust/Trade Regulation
  • Civil rights/Discrimination
  • Commercial Transactions
  • Corporation Formation/Alteration
  • Immigration and Naturalization
  • Intellectual Property Litigation
  • International/Foreign Law
  • Labor - Management Representation
  • Government/Municipal (Not bonds)
  • Tax - Preparation of Returns
  • Estate, Trust, Probate
  • Entertainment / Sports
  • Intellectual Property Services
  • Labor - Labor Representation
  • Pension & Employee Benefits
  • Mergers / Acquisitions
  • Oil, Gas or Mining
  • Real Estate - Commercial
  • Tax – Opinions
  • Worker's Compensation - Plaintiff
  • Personal BI/PD Plaintiff:
  • Banking / Financial Institutions
  • Real Estate – Residential
  • Real Estate - Land Use / Zoning
  • Real Estate - Title Examination
  • Securities
  • *Other

*Describe other services below:

Insurance History

Renewal Date

Insurer

Limit

Deductible

Retroactive Date (if applicable)

Current annual premium

Claims History (if applicable):

Claim 1
Date Claim or Incident Reported:


Amount Paid (Including Expenses):


Open/Closed:

Claim 2

Date Claim or Incident Reported:


Amount Paid (Including Expenses):


Open/Closed:

Claim 3

Date Claim or Incident Reported:


Amount Paid (Including Expenses):


Open/Closed:

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