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Firm
*
Contact Name
*
Street Address
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City
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State
*
Country
Zip
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Phone
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Fax
Email Address
*
Website Address
1. Please provide information for attorneys in your firm
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Attorney name
Years in private practice
Date join 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):
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Admiralty/ Marine Defense
Anti-Trust /Trade Regulation
Banking / Financial Institutions
Business Transaction/ Commercial Law
Civil/Comml Litigation-Defense
Civil/Comml 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)
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 coverage
Retroactive Date (if any)
MM slash DD slash YYYY
Current Professional Liability Carrier/ Program
Current Policy Expiration Date
MM slash DD slash YYYY
Annual Premium
Current 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/$5,000,000
Other
Other limit
Deductible
$1,000
$2,000
$2,500
$3,000
$4,000
$5,000
$10,000
$15,000
$25,000
$50,000
$75,000
$100,00
Other
Other debuctible
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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 below
6. Has the firm been involved in any mass tort/class action cases within the past five years ?
Yes
No
Please provide detail below
7. 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 below
8. Have you had or reported any Professional Liability claims or incidents in the last five years?
Yes
No
Please provide detail below
Please 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 Incom
Personal Umbrella Liability
Worker's Compensation Coverage
Employment Practices Liability
Step
1
of
14
7%
Credit Score
Do you have 3 month reserves?
Yes
No
Monthly Gross Income?
Income Type:
Base Income
Overtime
Commission
Present Employer for 2 or more years?
Yes
No
Student Loan Debt?
Yes
No
How much?
Deferred?
Yes
No
Monthly Payment
Any large installment payments such as Auto loans?
Yes
No
Total Monthly Payments
Total credit card debt
Any Judgements, Tax Liens or Discharge Bankruptcy in last 2 yrs?
Yes
No
Hidden
Remaining Income
Hidden
Housing Payment Max
Pre Qualified
Not Qualified
Prequalified for 100k to 200k
Prequalified for 200k to 300k
Prequalified for 300k plus