Lawyers Professional Liability Application

Please complete the application and submit or print and return via email, mail, or fax. Contact us with any questions at the number listed above.

Contact Information:


Current Insurance Coverage (If applicable):


Attorney Information:

Attorney Name DC* Yrs. in Practice Date of Hire # Hrs. Worked/Week Individual Attorney Retro Date (If applicable)

DC* = Designated Codes

O

Officers, Directors, Shareholders of company who are licenced attorneys

P

Parteners in a partnership

PT

Part-time lawyers (Fewer than 26 hours per week solely for application firm)

OC

Of Counsel Attorney

IC

Independent Contractor

S

Sole Proprietor

E

Employed Attorneys

R

Retired Partener


In the past 5 years, has any attorney had coverage declined, cancelled, or non-renewed? Or been subject to a reprimand, disciplinary action, etc?


In the past 5 years have there been any claims, or is anyone aware of any circumstances, incidents, errors, etc. that may result in claim?


Areas of Practice: Please note percentage of work done in each area

% Area % Area % Area
Administrative Law
Divorce w/Assests < $1M
Medical Malpractice*
Admiralty/Marine Law
Divorce w/Assests $1M-$5M
Natural Resources (Oil and Gas)
Adoption Law
Divorce w/Assests > $5M*
Personal Injury-Plaintiff
Antitrust/Trade Reg.
Environmental Law
Personal Injury-Defence
Arbitration/Madiation
Entertainment
Real Estate-Commercial
Bankruptcy
ERISA/Employee Benifits
Real Estate-Residential
Business Transactions/Contracts
Financial Institutions/Banks
Real Estate-Title/Abstracting
Civil Rights/Discrimination
Government Contracts/Claims
Securities*
Collection/Repossession
Gaurdianship/Juvenile
Social Security
Commercial Lit-Plaintiff
Immigration/Naturalization
Taxation
Commercial Lit-Defense
Insurance Defense
Worker's Comp-Plaintiff
Construction/Billing Contracts
Intellectual Property*
Worker's Comp-Defense
Consumer Claims
International Law
Wills, Trusts, Estates < $1M
Corporate Administrative
Labor Management
Wills, Trusts, Estates $1M-$5M
Corporate/Business Administration
Labor Union/Employee
Wills, Trusts, Estates > $5M
Corporate Mergers/Acquisitions
Local Government (not bonds)
Criminal
Mass Torts/Class Actions*

* = We may need additional information to provide a quote if you are working in these areas.


Does the firm have a confilict of interest avoidance system?

Does the firm use engagement/disengagement letters?




This is used for quotes only. Coverage is not bound by returning this form

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