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Lawyer’s Professional

Thank you for your interest. Please fill out the form below and we will be in touch soon!

Proposed Effective Date:
12:01 a.m. Standard Time at the address of the Applicant.
From*
To*
Are you currently insured?
- Yes
- No
I. GENERAL INFORMATION
1. Applicant*
2. Address*
Street Address County City State / Province / Region ZIP / Postal Code
3. Telephone Number:*
Contact Person*
Email*
II. APPLICANT’S PRACTICE
1. Practice Areas
Describe the Applicant’s practice by showing the approximate percentage of gross billable dollarsduring the past year derived from the following:
Total of all categories must equal 100%

CATEGORY A
Administrative
Please enter a number from 0 to 100.
Appellate
Please enter a number from 0 to 100.
Arbitration
Please enter a number from 0 to 100.
Criminal
Please enter a number from 0 to 100.
Immigration
Please enter a number from 0 to 100.
Mediation
Please enter a number from 0 to 100.
Municipal Law
Please enter a number from 0 to 100.

CATEGORY B
Government Law
Please enter a number from 0 to 100.
Title/Commercial
Please enter a number from 0 to 100.
Title/Residential
Please enter a number from 0 to 100.
Traffic
Please enter a number from 0 to 100.

CATEGORY C
International Law
Please enter a number from 0 to 100.
Juvenile
Please enter a number from 0 to 100.
Labor/ Management Representation
Please enter a number from 0 to 100.

CATEGORY D - Litigation:
Plaintiff: BI/PI
Please enter a number from 0 to 100.
Plaintiff: Class Action or Mass Tort
Please enter a number from 0 to 100.
Plaintiff: Medical Malpractice
Please enter a number from 0 to 100.
Plaintiff: Other Litigation
Please enter a number from 0 to 100.
Defense: Class Action
Please enter a number from 0 to 100.
Defense: Insurance
Please enter a number from 0 to 100.
Defense: (Excluding Med Mal)
Please enter a number from 0 to 100.
Defense: Medical Malpractice
Please enter a number from 0 to 100.
Defense: Other BI/PI
Please enter a number from 0 to 100.
Defense: Other Litigation
Please enter a number from 0 to 100.

CATEGORY E
Civil Rights
Please enter a number from 0 to 100.
Foreign Law
Please enter a number from 0 to 100.
Guardianships
Please enter a number from 0 to 100.

CATEGORY F
Admiralty
Please enter a number from 0 to 100.
Antitrust
Please enter a number from 0 to 100.
Banking
Please enter a number from 0 to 100.
Commercial Law
Please enter a number from 0 to 100.
Corporate Formation
Please enter a number from 0 to 100.
Foreclosures
Please enter a number from 0 to 100.
General Corporate Advice
Please enter a number from 0 to 100.
Lobbying
Please enter a number from 0 to 100.
Tax Preparation
Please enter a number from 0 to 100.

CATEGORY G
Bankruptcy
Please enter a number from 0 to 100.
Collection
Please enter a number from 0 to 100.
Construction
Please enter a number from 0 to 100.
Estate Planning
Please enter a number from 0 to 100.
Estate, Trust, Wills
Please enter a number from 0 to 100.
Family Law
Please enter a number from 0 to 100.
Patent,Trademark, Copyright Litigation
Please enter a number from 0 to 100.
Tax Opinions
Please enter a number from 0 to 100.

CATEGORY H
Entertainment
Please enter a number from 0 to 100.
Fiduciary
Please enter a number from 0 to 100.
Investment Counseling
Please enter a number from 0 to 100.
Labor/Union Representation
Please enter a number from 0 to 100.
Mergers/Acquisitions (Corporate)
Please enter a number from 0 to 100.
Purchase/sale of business
Please enter a number from 0 to 100.

CATEGORY I
Adoptions
Please enter a number from 0 to 100.
Environmental Law
Please enter a number from 0 to 100.
High Profile Divorce (greater than 10 Million Marital Assets)
Please enter a number from 0 to 100.
Limited Partnership Formation
Please enter a number from 0 to 100.
Oil/Gas/Mining
Please enter a number from 0 to 100.
Real Estate Development
Please enter a number from 0 to 100.

CATEGORY J
Real Estate Syndication
Please enter a number from 0 to 100.
Securities / Bonds
Please enter a number from 0 to 100.

CATEGORY K
Real estate closings/general
Please enter a number from 0 to 100.

CATEGORY L
Tribal Law
Please enter a number from 0 to 100.
Patent, Trademark, Copyright Prosecution or Searches
Please enter a number from 0 to 100.
Water Law
Please enter a number from 0 to 100.

Total Gross %
2. ATTORNEYS
A) Please list the number of all attorneys in categories below as an expression of the number of years employed by the Applicant Firm.

Less than 1 year
Please enter a number greater than or equal to 0.
1 year
Please enter a number greater than or equal to 0.
2 years
Please enter a number greater than or equal to 0.
3 years
Please enter a number greater than or equal to 0.
4 years
Please enter a number greater than or equal to 0.
5 years+
Please enter a number greater than or equal to 0.
TOTAL*

Do you have any attorneys working less than 20 hours per week?*
- Yes
- No
B) Total “Of Counsel” or Independent Contractors*
Include only “Of Counsels” or IC’s who averageworking for you 20 hours or less per week.. (Otherwise, include in Category A.)
3. CURRENT COVERAGE
If not currently insured, indicate the desired limits and deductions.
a. Insurance Company
b. Expiration Date
Retroactive Date (If applicable)
c. Premium
Limit*
Deductible*
4. CLAIMS/CIRCUMSTANCES/DISCIPLINARY
a. Has any professional liability claim or suit been made in the past five (5) years against the firm or its predecessor firm (s) or any current or former member of the firm or its predecessor firm(s)?*
- Yes
- No
TOTAL NO. OF CLAIMS
b. After inquiry, does any firm member know of any circumstance, situation, act, error or omission that could result in a professional liability claim or suit against the firm or its predecessor firm(s) or any of the current or former members of the firm or its predecessor firm(s)?*
- Yes
- No
TOTAL NO. OF CIRCUMSTANCES
If “Yes” to a. or b., please attach a copy of the Claim Supplement you completed for your current Insurer andupdate as needed. Also, forward 5 year loss runs if available.
c. Has any current or former member of the firm ever been refused admission to practice, disbarred, suspended, fined or held in contempt by any court, state or local bar association, administrative agency or regulatory body?*
- Yes
- No
If “Yes,” please provide full details.
5. SUITS FOR FEES
a. How many suits for collection of fees have been filed against firm clients in the last two (2) years?*
If none, enter zero.
6. ADMINISTRATIVE CONTROLS
a. Do you maintain a Docket Control System with at least two Independent date controls?*
- Yes
- No
b. Is it computerized?*
- Yes
- No
c. Do you maintain a Conflict of Interest Avoidance System?*
- Yes
- No
d. Is it computerized?*
- Yes
- No
e. Do you utilize engagement letters for all clients?*
- Yes
- No
This form will be used to provide your firm with an estimate of premium cost. Coverage can only be bound after an application form is completed and accepted by the Company.

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