EmailMe Form - Victor Bary attorney form

Name

Phone #

Email

Address

Street Address City State / Province / Region Postal / Zip Code

1. FIRM’S PRACTICE - Describe Firm’s practice by listing the top 3 areas of law you focus on.

2. CURRENT COVERAGE:

Carrier

Expiration Date

# of Attorneys Last Year

Deductible

Limit of liability: $

Premium Amount

Have you been insured for at least 5 years?

Yes

No

If no, please provide the date from which you have been continuously insured?

Key For Below

*Designation Codes (D/C)
O = Officers, Directors or Shareholders of the corporation who are licensed as lawyers S = Sole Proprietor
E = Employed lawyers (must be employee of applicant) P = Partners of a partnership
C = Of counsel attorneys for whom coverage is desired
PT = Part-time lawyers (must work less than 26 hours per week in the private practice of law solely on behalf of the
applicant firm)

3.ATTORNEYS - List their names, DC, Date admitted to bar, Years of practice, date join the firm. Average # of
hours worked
per week
(if Of Council)

4. CLAIMS/CIRCUMSTANCES/DISCIPLINARY:

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 #

After inquiry, does any firm member know of any circumstance, situation, act, or 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) years?

Yes

No

Total #

If “yes” to either A or B, please attach a copy of the Claim Supplement you completed for your
current Insurer and update as needed.

File Upload

Has any 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: How many suits for collection of fees have been filed against clients in the last two (2) years?

6.ADMINISTRATIVE CONTROLS: Do you maintain a Docket Control Systems with at least two Independent date controls?

Yes

No

Is it computerized?

Yes

No

Do you maintain a Conflict of Interest Avoidance system?

Yes

No

Is it computerized?

Engagement letters

Non-engagement letters

Disengagement letters

Retainer agreements

Have 50% or more of the attorneys attended CLE in the past 12 months?

Yes

No

Does/has any attorney serve(d) as a director/officer, or have equity interest in a client?

Yes

No

Does any single client represent 10% or more of your firm’s total gross billings?

Yes

No

Number of support staff

Yes

No

7a. Do any of your attorneys/employees act as title agents?

Yes

No

7b. If yes, does the firm or any of its members own or control a title agency?

Yes

No

Remarks

2. CURRENT COVERAGE:

Key For Below

4. CLAIMS/CIRCUMSTANCES/DISCIPLINARY:

If “yes” to either A or B, please attach a copy of the Claim Supplement you completed for your current Insurer and update as needed.

If “yes” to either A or B, please attach a copy of the Claim Supplement you completed for your
current Insurer and update as needed.