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Lawyers Professional Liability Quote Form
1. Applicant Information
Name
Firm Name:
*
Address
City
State
Zip
Phone (with area code)
Fax (with area code)
Email
Website (URL)
Applicant is: (Please select)
Proprietorship
Partnership
Corporation
PLLC
LLP
LLC
Other
Other
Year Firm Established:
Has the applicant merged with or acquired any firms in the last three (3) years? Please select one.
Yes
No
2. Limits Requested - Per Claim/Aggregate (check all that apply)
$100,000/$300,000
$200,000/$500,000
$250,000/$750,000
$500,000/$1,000,000
$1 million/$1 million
$1 million/$2 million
$2 million/$2 million
Other
Other
3. Deductible Requested (Please select one)
$1,000
$2,500
$5,000
$10,000
4. Personnel - List all Lawyers to be covered: (Do NOT list "of counsels", Independent contractor lawyers, or per Diem lawyers)
Name
Status Designation Code*
State(s) Admitted to Practice
Year First Admitted to Bar
Year Lawyer Joined Applicant Firm
1.
Name
Status Designation Code*
State(s) Admitted to Practice
Year First Admitted to Bar
Year Lawyer Joined Applicant Firm
2.
Name
Status Designation Code*
State(s) Admitted to Practice
Year First Admitted to Bar
Year Lawyer Joined Applicant Firm
3.
Name
Status Designation Code*
State(s) Admitted to Practice
Year First Admitted to Bar
Year Lawyer Joined Applicant Firm
4.
Name
Status Designation Code*
State(s) Admitted to Practice
Year First Admitted to Bar
Year Lawyer Joined Applicant Firm
5.
Name
Status Designation Code*
State(s) Admitted to Practice
Year First Admitted to Bar
Year Lawyer Joined Applicant Firm
6.
Name
Status Designation Code*
State(s) Admitted to Practice
Year First Admitted to Bar
Year Lawyer Joined Applicant Firm
Status Designation Code: S–Sole Proprietor, P–Partner/Member, E–Employed Lawyer
Hours of service provided to the applicant per year by "of counsel", independent contractor lawyers and per diem lawyers.
*
Total number of lawyers who left the firm in past year.
*
Current total number of non-lawyer employees
*
5. Areas of Practice (Please fill in all that apply)
A. Indicate the percentage (%) of gross billable dollars by area of practice for the last fiscal year.
TOTAL MUST EQUAL 100.
Admiralty/Marine
*
Entertainment
*
Real Estate-Title Work
*
Anti-Trust Trade
*
Environmental
*
Real Estate-Condo Office
*
Arbitration / Mediation
*
ERISA
*
Securities - Federal
*
Banking
*
Es. Plan/Probate/Will
*
Securities-State
*
Securities-State
*
Bankruptcy
*
Bankruptcy
*
Securities-Private Placement
*
Bodily Injury/Defence
*
International Law
*
Securities-Bonds
*
Bodily Injury/Plaintiffs
*
Investment Counseling
*
Tax Opinions
*
Collection Repossession
*
Labor Relations
*
Tax Preparation
*
Copyright/Patent/TM
*
Public Utilities
*
Corporate
*
Real Estate-Residential
*
Workers Comp/Defense
*
Criminal
*
Real Estate-Commercial
*
Workers Comp/Plaintiff
*
Real Estate-Condo Office
*
Domestic Relations
*
Real Estate-Synd. Devel.
*
Social Security Disability
*
Other
*
B. Does the applicant have any high-profile clients who are entertainers, sports figures, or public officials? If "Yes", please explain by attachment
Yes
No
C. Does the applicant have discretionary investment authority of any clients? If "Yes", please list total number of clients.
Yes
No
Total number of clients:
*
Is any one client account for more than $500,000?
Yes
No
Is the authority limited and in writing?
Yes
No
D. In the last five (5) years, has any attorney with the Applicant firm, represented any financial institution? Financial institution means any savings and loan association, bank, credit union,savings bank, banking institution or subsidiary of lending affiliate thereof. If "Yes", complete the
Financial Institutions Supplemental Application
.
Yes
No
E. Does any firm attorney serve as a director, officer, trustee (other than estate trusts), partner, or employee of any client? If "Yes", complete the
Outside Interests Supplemental Application.
Yes
No
F. Does any firm member exercise fiduciary control or possess any ownership interest in any client or business venture with a client?
Yes
No
G. Does the applicant have ownership in a title agency? If "Yes", please complete the Title Agency Supplemental Application.
Yes
No
6. Firm Policies and Procedures
A. Use
engagement letters
on all new matters?
Yes
No
Require clients to sign
engagements/agreements
?
Yes
No
Use
nonengagement and disengagement
letters?
Yes
No
Use any of the following
conflict avoidance
methods:
Oral/Memory-Yes
Oral/Memory-No
Computer-Yes
Computer-No
Conflict Committee-Yes
Conflict Committee-No
Index File-Yes
Index File-No
Update its
conflict avoidance
system at least weekly?
Yes
No
Cross-check
conflicts
by processor, merged, or acquired firm?
Yes
No
Insist on obtaining written waiver from its clients in order to perform on-going services when an
actual/potential conflict
exists?
Yes
No
Allow attorneys to
enter into business
with firm clients?
Yes
No
Require
disclosure
if such relationships are permitted?
Yes
No
Maintain a
calendar system
using these methods:
Single Calendar-Yes
Single Calendar-No
Dual Calendar-Yes
Dual Calendar-No
Computer-Yes
Computer-No
Master Listing-Yes
Master Listing-No
Use two individuals to maintain its
calendar system
?
Yes
No
Update its
calendar system
at least weekly?
Yes
No
Place ultimate responsibility for
calendar system
with a firm lawyer?
Yes
No
B. If you are a sole practitioner, have you designated a lawyer(s) who will be responsible for your affairs if you are absent from an extended period(s) of time?
Yes
No
C. What is the total number of hours of continuing legal education within the last year for all lawyers?
D. How many times has the Applicant sued a client for unpaid fees in the last year?
E. Does any single client account for more than twenty-five (25) percent (%) of the Applicant's gross annual billings? If "Yes", please identify client, nature of client's business, and percentage of billings by attachment.
Yes
No
7. Claims, Incidents, & Disciplinary Actions
After inquiry, has any lawyer to be insured under this policy:
A. ever had professional liability insurance cancelled or non-renewed? If "Yes", please explain by attachment.
Yes
No
B. even been disbarred or been the subject of reprimand, censure, sanction, or other disciplinary action, or been refused admission to the Bar? If "Yes", please explain by attachment.
Yes
No
C. been the subject of a professional liability claim or suit in the past five (5) years?
Yes
No
D. knowledge of any circumstance, act, error, or omission that could result in a professional liability claim? If "Yes", please identify client, nature of client's business, and percentage of billings by attachment.
Yes
No
8. Prior Insurance
Current Prior Acts Exclusion date and/or retroactive date:
Please list professional liability insurance carried by the Applicant and Predecessor Firms over the last three (3) years:
Inception From (MO-DAY-YR)
Insurance Company
Policy Number
Limit of Liability and Deductible
1.
Inception From (MO-DAY-YR)
Insurance Company
Policy Number
Limit of Liability and Deductible
2.
Inception From (MO-DAY-YR)
Insurance Company
Policy Number
Limit of Liability and Deductible
3.
Inception From (MO-DAY-YR)
Insurance Company
Policy Number
Limit of Liability and Deductible
Is the Applicant being covered by an Extended Reporting Period Endorsement? If "Yes", please give details.
Yes
No
Does your current policy INCLUDE predecessor firm coverage?
Yes
No