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Lawyers' Professional Liability Program
Firm Information
(* indicates required field)
Firm Name:
*
Number of Attorneys:
Contact Name:
*
Firm Address:
City:
State:
Zip:
County:
Year Firm Established:
Email:
Phone:
*
Fax:
Areas of Practice
(enter the % of total billable hours)
Admiralty/Marine Defense:
Admiralty/Marine Plaintiff:
Anti-Trust Trade Regulation:
Bank/Financial Institutions:
Bankruptcy:
Business Transaction/Commercial Law:
Civil/Commercial Litigation Defense:
Civil/Commerical Litigation Plaintiff:
Civil Rights/Discrimination:
Collection:
Construction (Building Contracts):
Consumer Claims:
Corporate Business Organization:
Criminal:
Environmental Law:
Family Law:
Government Contracts/Claims:
Immigration/Naturalization:
Intellectual Property:
International Law:
Labor Law - Union Representative:
Labor Law - Management Representative:
Local Government:
Natural Resources/Oil and Gas:
Personal Injury/Property Damage - Defense:
Personal Injury/Property Damage - Plaintiff:
Real Estate/Title - Commercial:
Real Estate/Title - Residential:
Securities (SEC):
Taxation:
Wills, Estates, Probates & Planning:
Workers' Comp. Defense:
Workers' Comp. Plaintiff:
Other:
Attorney Information
Attorney 1
Attorney's Name:
Bar Admission Date:
Date and time
Now
Date Joined Firm:
Date and time
Now
Relation to Firm:
Select...
Officer
Partner
Solo
Employed Attorney
Independent Contractor
Of Counsel
Number of Weekly Hours:
Attorney 2
Attorney's Name:
Bar Admission Date:
Date and time
Now
Date Joined Firm:
Date and time
Now
Relation to Firm:
Select...
Officer
Partner
Solo
Employed Attorney
Independent Contractor
Of Counsel
Number of Weekly Hours:
Attorney 3
Attorney's Name:
Bar Admission Date:
Date and time
Now
Date Joined Firm:
Date and time
Now
Relation to Firm:
Select...
Officer
Partner
Solo
Employed Attorney
Independent Contractor
Of Counsel
Number of Weekly Hours:
Attorney 4
Attorney's Name:
Bar Admission Date:
Date and time
Now
Date Joined Firm:
Date and time
Now
Relation to Firm:
Select...
Officer
Partner
Solo
Employed Attorney
Independent Contractor
Of Counsel
Number of Weekly Hours:
Insurance History
Does your firm currently have liability coverage?:
Select...
Yes
No
Carrier:
Premium:
Expiration Date:
Date and time
Now
Retroactive Date (prior acts):
Date and time
Now
Limit Per Claim ($):
Aggregate Limit ($):
Deductible ($):
In the last 5 years, has any member of your firm been disciplined or denied the right to practice?:
Select...
Yes
No
Has the firm ever been non-renewed, canceled or declined coverage?:
Select...
Yes
No
If 'yes', please explain:
Does your firm have a docket system with two independent date controls cross checked by a separate individual?:
Select...
Yes
No
Does the firm use engagement/disengagement letters?:
Select...
Yes
No
Number of suits for fees filed against clients in the past two years:
Claim Information
Please list all claims for last 5 years
Date of Claim
Reserve Amount
Paid Amount
Status
Claim 1
Date and time
Now
Select...
Open
Closed
Incident
Closed No Pay
Claim 2
Date and time
Now
Select...
Open
Closed
Incident
Closed No Pay
Claim 3
Date and time
Now
Select...
Open
Closed
Incident
Closed No Pay
DISCLAIMER
: This form is for estimating purposes only. Coverage may be bound only upon submission and acceptance of a completed application.
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