Lawyers Professional Liability Quote Form

1. Applicant Information

Applicant is: (Please select)
Has the applicant merged with or acquired any firms in the last three (3) years? Please select one.

2. Limits Requested - Per Claim/Aggregate (check all that apply)


3. Deductible Requested (Please select one)

4. Personnel - List all Lawyers to be covered: (Do NOT list "of counsels", Independent contractor lawyers, or per Diem lawyers)

 NameStatus Designation Code*State(s) Admitted to PracticeYear First Admitted to BarYear Lawyer Joined Applicant Firm
Status Designation Code: S–Sole Proprietor, P–Partner/Member, E–Employed Lawyer

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.
B. Does the applicant have any high-profile clients who are entertainers, sports figures, or public officials? If "Yes", please explain by attachment
C. Does the applicant have discretionary investment authority of any clients? If "Yes", please list total number of clients.
Is any one client account for more than $500,000?
Is the authority limited and in writing?
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.
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.
F. Does any firm member exercise fiduciary control or possess any ownership interest in any client or business venture with a client?
G. Does the applicant have ownership in a title agency? If "Yes", please complete the Title Agency Supplemental Application.

6. Firm Policies and Procedures

A. Use engagement letters on all new matters?
Require clients to sign engagements/agreements?
Use nonengagement and disengagement letters?
Use any of the following conflict avoidance methods:
Update its conflict avoidance system at least weekly?
Cross-check conflicts by processor, merged, or acquired firm?
Insist on obtaining written waiver from its clients in order to perform on-going services when an actual/potential conflict exists?
Allow attorneys to enter into business with firm clients?
Require disclosure if such relationships are permitted?
Maintain a calendar system using these methods:
Use two individuals to maintain its calendar system?
Update its calendar system at least weekly?
Place ultimate responsibility for calendar system with a firm lawyer?
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?
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.

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.
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.
C. been the subject of a professional liability claim or suit in the past five (5) years?
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.

8. Prior Insurance

Please list professional liability insurance carried by the Applicant and Predecessor Firms over the last three (3) years:
 Inception From (MO-DAY-YR)Insurance CompanyPolicy NumberLimit of Liability and Deductible
Is the Applicant being covered by an Extended Reporting Period Endorsement? If "Yes", please give details.
Does your current policy INCLUDE predecessor firm coverage?