EmailMe Form - Lawyers Professional Liability Coverage

Full Name of Applicant *

please provide entity name if a corporation or LLC

Principal business premises address: *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Secondary practice locations: *

None if no other locations

Phone Number *

### - ### - ####

Website Address

Date Established *

MM / DD / YYYY

Business is a: *

Is the applicant a single lawyer firm? *

If yes, is there a lawyer that will be responsible for the practice if Applicant is unable to work for an extended period of time?

Please provide name, address, and phone number for back-up lawyer

List the names of all predecessor firms of the applicant. A "Predecessor Firm" is any legal entity which was engaged in the practice of law to whose financial assets and liabilities the Applicant is the majority successor in interest.

Name of Predecessor Firm?

*If any more than one Predecessor Firm, please list in remarks at bottom of quote form*

Date Established?

MM / DD / YYYY

% of Lawyers that are members of Applicant Firm?

Did Firm Dissolve, Change Name or Form, or Continues to Exist?

Insurer on Last Professional Liability Insurance?

Retroactive Date on Predecessor Firm's Professional Liability Insurance Policy?

Please Provide the Applicant's total annual gross revenues for the last 3 year. If newly established, provide estimated annual gross revenues for the current year.

Last 12 months *

$ Dollars . Cents

1st Prior Year *

$ Dollars . Cents

2nd Prior Year *

$ Dollars . Cents

=

Please Provide the names of all lawyers who are presently officers, partners, employed lawyers, of counsels or retired partners of the Applicant and complete the information requested for each lawyer.

Name of Lawyer

First Last

Name of Lawyer

First Last

Designation

Hours worked per week

Year admitted to Bar

MM / DD / YYYY

Year admitted to Bar

MM / DD / YYYY

Joined Date with Applicant

MM / DD / YYYY

Joined Date with Applicant

MM / DD / YYYY

Bar Certified Practice Area Specialist?

Name of Lawyer

First Last

Name of Lawyer

First Last

Designation

Hours worked per week

Year admitted to Bar

MM / DD / YYYY

Year admitted to Bar

MM / DD / YYYY

Joined Date with Applicant

MM / DD / YYYY

Joined Date with Applicant

MM / DD / YYYY

Bar Certified Practice Area Specialist?

Name of Lawyer

First Last

Name of Lawyer

First Last

Designation

Hours worked per week

Year admitted to Bar

MM / DD / YYYY

Year admitted to Bar

MM / DD / YYYY

Joined Date with Applicant

MM / DD / YYYY

Joined Date with Applicant

MM / DD / YYYY

Bar Certified Practice Area Specialist?

How many Lawyers are currently employed by the applicant? *

How many Lawyers left the Applicant last year? *

How many Paralegals are currently employed by the applicant? *

How many Paralegals left the Applicant last year? *

How many non-lawyer employees work for the applicant? *

How many non-lawyer employees left the Applicant last year? *

Does the applicant have a full-time office administrator? *

Does the applicant have a management/executive committee? *

If yes, how many members comprise such committee?

If yes, how often does the committee meet?

In the past 5 years, has any lawyer proposed for this coverage served or currently serve as director, officer, trustee, or partner of any entity which is or was a client at the time of service? *

In the past 5 years, has any lawyer proposed for this coverage held an equity or financial interest in a client? *

Is any lawyer proposed for this coverage an employee or any organization, entity of governmental body other than the applicant? *

If yes, please provide details

Is any lawyer proposed for this coverage engaged in any professional or business activities other than the private practice of law? *

If yes, please provide details

AREAS OF PRACTICE

Of the list below, please allot what percentage of time is devoted to the following areas of practice:
(*Total percentage across all areas should total 100%*)

Administrative

Admirality/Marine

Adoptions/Domestic Children

Adoptions/Foreign Children

Antitrust/Trade Regulation

Appellate

Arbitration

Bankruptcy

Business/Commercial Law

Collections

Communications/FCC

Construction Law

Corporate Law Administrative

Corporate Law Formation

Corporate Law Mergers & Acquisitions

Corporate Law Stock Options - Any Involvement

Criminal Law

Elder Law

Energy/Natural Resources

Entertainment/Sports

Environmental Law

Estate, Trust, Probate, Wills

Family/Domestic Custody/Child Support

Family/Domestic Divorce - Assets under 1 mil

Family/Domestic Dirorce - Assets over 1 mil

Financial Institutions

Government/Municipal

Healthcare

Immigration/Naturalization

Intellectual Property

International Law

Juvenile Law

Labor Relations - Union

Labor Relations - Management

Plaintiff Work Civil Rights/Discrimination

Plaintiff Work Class Action/Mass Tort

Plaintiff Work PI/PD Litigation

Plaintiff Work Medical Malpractice

Plaintiff Work Professional Liability

Plaintiff Work Social Security

Plaintiff Work Workers Compensation

Plaintiff Work Other

Defense Work Class Action/Mass Tort

Defense Work PI/PD Defense

Defense Work Medical Malpractice

Defense Work Other

Real Estate Commercial Transactions

Real Estate Foreclosure/Repossession

Real Estate Limited Partnership

Real Estate Syndication/Development

Real Estate Title Work

Securities Municipal Bonds

Securities Private Stock Offerings

Securities Public Stock Offerings

Tax Options

Tax Returns

Tax Shelter Related Work

Other (Please describe)

Have any suits for collection of fees been filed against any client in the last 2 years? *

If yes, how many?

If yes, please provide date(s) filed, Name of Client, $ amount sought, and the status and/or result

If yes, what steps have been taken by the Applicant to reduce or avoid the necessity of fee collections suits in the future?

When evaluating whther a case should be sent for collection, does the applicant review the file for the purpose of evalutation whether the possibility of a counterclaim alleging malpractice might be filed in response thereto? *

Does the Applicant accept cases where the cause of action arises and is adjudicated outside of the Applicant's local jurisdiction (i.e., in another state)? *

If yes, does the Applicant refer such cases to local counsel?

Has the Applicant outsourced any work inthe last two years, either domestically or out of the country? *

Does the applicant have any single client or group of related clients which produce more than 25% of total gross billings in the last 24 months? *

If yes, provide the percentage of gross billings, name of client, business activities of client, and services provided on behalf of client

In the last 5 years, has the Applicant accepted client securities or other forms of compensation in lieu of fee? *

If yes, please provide details

Does the Applicant share office space with any other lawyer? *

If yes, is the letterhead shared?

If yes, is there any staff shared?

If yes, please provide details

FIRM MANAGEMENT AND ADMINISTRATION

Does the Applicant's docket control system include: *

	Yes	No
Computer System?
Dual Calendar?
Immediate entry of all dates?
Master listings?
Provisions for illness of document administrator?
Single Calendar?
Tickler System?
Verification of completion of events?

How frequently are deadlines cross-checked? *

Does the docket control system produce a daily or weekly calendar? *

Does the applicant maintain a system to avoid potential conflicts of interest? *

If yes, please explain

Please give the percentage of matters that the Applicant sends:

An engagement letter when accepting a representation *

A non-engagement letter when declining a representation *

A disengagement letter when ceasing a representation *

Does the Applicant have a policy prohibiting its attorneys from participating as a partner, officer, or director in any entity other than the Applicant when the Applicant provides legal services? *

If No, please explain

A formal training program for lawyers joining the firm? *

Internal (risk management audits performed on a regular basis? *

Annual audited financial statements produced each year? *

INSURANCE AND CLAIM HISTORY

What limits of Liability are you requesting? (Per Claim/Annual Aggregate) *

What deductible are you requesting?

Please list the Lawyers Professional Liability Insurance for the last 3 years.

Year 1 - Company Name/Limits of Liability/Deductible/Premium/
Expiration Dates/Retroactive Date/Number of Lawyers Covered *

If none, state so

Year 2 - Company Name/Limits of Liability/Deductible/Premium/
Expiration Dates/Retroactive Date/Number of Lawyers Covered *

If none, state so

Year 3 - Company Name/Limits of Liability/Deductible/Premium/
Expiration Dates/Retroactive Date/Number of Lawyers Covered *

If none, state so

Has any insurer declined, canceled, or nonrenewed any Lawyers Professional Liability Insurance or any similar insurance on behalf of any person(s) or entity(ies) proposed for this insurance? *

If yes, Please provide details

Has any lawyer Applicant, past or present, ever ben refused admission to practice, disbarred, suspended, reprimanded, sanctioned, fined, or held in contempt by any court, state or local bar association, administrative agency, or regulatory body? *

If yes, please provide FULL details including the court's final decision

Is any person(s) or entity(ies) proposed for this insurance currently under investigation, or has any disciplinary complaint or grievance been made to any court, bar association, administrative agency or regulatory body in the last 5 years that resulted in any formal censure or other formal action? *

If yes, please provide details

Has (Have) any Professional Liability claim(s) been made against the Applicant or any person or entity proposed for coverage or any predecessor firm(s) in the past 5 years? *

If yes, provide number of claims

Is (are) any person(s) or entity(ies) proposed for this insurance aware of any fact, error, omission, circumstance or situation that might provide grounds for any claim under the proposed insurance? *

If yes, please provide number and details

Referring Agent