Lawyers Professional Liability Insurance

Premium Estimate Questionnaire
- Complete this form to receive a premium estmate. Quotations and coverage may be issued only upon acceptance of a fully completed application.
* REQUIRED FIELDS

To which attorney in your firm should insurance matters be addressed?

Contact Name *

First Name

Last Name

Firm Name *

Address *

Address line 2

City *

State *

Zip Code *

Phone *

Fax

Email *

 

Please indicate, in the spaces below, the number of attorneys in your firm according to their years in practice:

 

< 1 year

1 - 2 years

2 - 3 years

3 - 4 years

4 - 5 years

5 + years

of Counsel

Total Attorneys

 

What percentages of time (not income) do you spend in the following practice specialties?

(Indicate % in whole numbers, total must equal 100%)

 

Anti-Trust / Trade Regulation

Business Transactions Commercial Law

Collection and Bankruptcy

Business Transactions Entertainment

Civil Rights / Discrimination

Governmane Contracts / Claims

Immigration / Naturalization

Wills, Estates, Trust and Probate

Consumer Claims

Defense-Personal Injury

Criminal

International Law

Local Government

Family Law

Environmental Law

Admiralty / Marine

Corp Business Mergers / Acquisitions

Corp Business Formations / Alterations

Construction (Building Contracts)

Workers Compensation Defense

Labor Law

Securities (S.E.C)

Taxation

Intellectual Property

Personal Injury / Prop Damage Plaintiff

Workers Compensation Plaintiff

Real Esatate / Title Commercial

Real Esatate / Title Residential

Banking / Financial Institutions

Natural Resources / Oil & Gas

Other

Explain Other

 

Your Claim History

Have you had or reported any claims in the last 5 years? None One Two Three or More

Amount Paid, Including Defense Expenses (if closed)

 

Date Last Claim Reported

Reserve Amount (if open)

 

Your Insurance History

How long have you been continuously insured? (yrs)

Current Professional Liability Isurer

Current Policy Expiration *

Current Renewal Premium *

Current Liability Limit

Current Deductible

Select One Per Claim Aggregate