Attorney Professional Liability

Name of Firm *
Address *
Phone
Fax
Email *

Attorneys to be Insured w/designations Date Admitted to the Bar Date Joined Firm If Part-Time Numbers of Hours Retroactive Date(If any)
Internal Controls and General Questions:       Insurance History  
Does the firm have a conflict avoidance system? Yes No   Current carrier
Does the firm regularly use engagement letters? Yes No   Expiration date:
Does the firm regularly use declination letters? Yes No   Limits:
Does the firm have a peer/addociate review system? Yes No   Deductible:
Are there 2 calendars to track important dates? Yes No   Premium:
Are there calendars crossed checked by 2 people? Yes No   Year firm established:
How many suits for fees in the past 2 years   Retroactive date:


Areas of Practice (% of gross billings from each area of practice)
% Administrative Law % Elder Law/Social Security % Probate & Trst Administration
% Arbitration/Mediation Labor Law Plaintiff Litigation
% Bankin/Financial Institutions % Employee/Union Rep. % Class Action
% Bankruptcy % Management Rep. % Commercial/Corporate
% Civil Rights/Discrimination % Employee Benefits/ERISA % Medical Malpractica
Civil Litigation % Entertainment/Sports Law % Personal or Bodily Injury
% Defendant Representation Environmental Law % Work Comp/Spcial Security
% Plaintiff Representation % Litigation Real Estate
% Collection/Repossession % Regulatory % Residential
% Construction Law % Family Law - not divorce % Commercial
Corporate % Family Law - divorce % Landlord/Tenant
% General % Guardianship/Juvenile % Title
% Formation/Alteration % Immigration/Naturalization % Syndication/Development
% Mergers/Acquisition % International Law % School Law
% Copyright/Trademark % Investment/Money Mgt % Securities Law
% Criminal Taxation
Defense Litigation Municipal Law % Individual
% Commercial/Corporate % Zomin & Planning % Commercial
% Bodily Injury/PErsonal Injury % Other- not Bonds % Water Rights
% Insurance Co. Representation Oil/Gas/Natural Resources % Wills/Trusts/Estates
% Workers Compensation % Patent % Other - If > 5% describe


Claims/Incidents/Bar Activity :
Amy claims/grievances/Incidents in the past 5 years? Yes No
If Yes, how many? and provide brief explanation with date reported, anounts paid or reserved, and defense expense to date, if any, for each item

This form is for a premium indication only. Please return to above indicated with a sample letter head. To receive a "Quotation" a fully completed application will be required.