Your Premium Estimate Starts Here Lawyers Professional Liability Insurance Firm*Contact Name*Street Address*City*State*CountyZip*Phone*FaxEmail Address* Website Address 1. Please provide information for attorneys in your firm*Attorney nameYears in private practiceDate joined the firm# Of weekly hours 2. Please tell us what percentage of Billable Hours- not income-- you spend in the following areas of practice (please express in whole numbers):*Admiralty/ Marine DefenseAnti-Trust /Trade RegulationBanking / Financial InstitutionsBusiness Transaction/ Commercial LawCivil/Comml Litigation-DefenseCivil/Comml Litigation-Plaintiff ( not personal injury)Civil Rights/ DiscriminationCollection and BankruptcyConstruction (Building Contracts)Consumer ClaimsCorporate Business OrganizationCriminalEnvironmental LawFamily LawGovernmental Contracts/ClaimsImmigration/ NaturalizationIntellectual Property (Patent, Trademark, Copyright)International LawLabor Management Rep.Labor Union Rep.Local GovernmentNatural Resources/ Oil and GasPersonal Injury/ Property Damage- DefensePersonal Injury/ Property Damage- PlaintiffReal Estate/ Title- CommercialReal Estate/ Title- ResidentialSecurities (SEC)TaxationWills, Estate,Trust and ProbateWorkers’ Compensation - DefenseWorkers’ Compensation – PlaintiffOther (describe below)Admiralty/ Marine Defense*Anti-Trust /Trade Regulation*Banking / Financial Institutions*Business Transaction/ Commercial Law*Civil/Comm'l Litigation-Defense*Civil/Comm'l Litigation-Plaintiff ( not personal injury)*Civil Rights/ Discrimination*Collection and Bankruptcy*Construction (Building Contracts)*Consumer Claims*Corporate Business Organization*Criminal*Environmental Law*Family Law*Governmental Contracts/Claims*Immigration/ Naturalization*Intellectual Property (Patent, Trademark, Copyright)*International Law*Labor Management Rep.*Labor Union Rep.*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, Estate,Trust and Probate*Workers’ Compensation - Defense*Workers’ Compensation – Plaintiff*Other (describe below)*Other describe*Total (Must equal 100%)*3. Please tell us about your current coverageRetroactive Date (if any) MM slash DD slash YYYY Current Professional Liability Carrier/ ProgramCurrent Policy Expiration Date MM slash DD slash YYYY Annual PremiumCurrent Limits$100,000/$300,000$250,000/$500,000$500,000/$500,000$500,000/$1,000,000$1,000,000/$1,000,000$1,000,000/$2,000,000$2,000,000/$2,000,000$2,000,000/$4,000,000$3,000,000/$3,000,000$4,000,000/$4,000,000$5,000,000/$5,000,000OtherOther limitDeductible$1,000$2,000$2,500$3,000$4,000$5,000$10,000$15,000$25,000$50,000$75,000$100,00OtherOther debuctible*4. Has the firm been continuously insured for malpractice for the last five years? Yes No 5. Has the firm's coverage ever been non-renewed, cancelled, rescinded or declined by another carrier? Yes No Please provide detail below6. Has the firm been involved in any mass tort/class action cases within the past five years ? Yes No Please provide detail below7. Have any of the firm's attorneys been the subject of any disciplinary action or had any complaints filed against them in the last 5 years or is still pending? Yes No Please provide detail below8. Have you had or reported any Professional Liability claims or incidents in the last five years? Yes No Please provide detail belowPlease check if you are interested in information on any of the other plans we offer: Office Property Coverage Cyber Liability Insurance Disability Income Short-term Health Insurance Business Overhead Expense Term Life Insurance Employee Disability Income Personal Umbrella Liability Workers' Compensation Coverage Employment Practices Liability
