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?

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

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

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

    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 rightsuse_label_element/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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