GET AN ONLINE QUOTE Firm InformationFirm Name*Contact Person*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone*FaxEmail* Year Established*Attorney InformationPlease provide attorney information below by Adding Attorneys Manually OR by Uploading a Roster Document.*Add Attorneys ManuallyUpload a Roster DocumentList*Attorney NameBar Admission YearHire Date (mm/dd/yy)Hours (weekly)Retroactive Date (if different than date of hire) Upload a Roster Document* Drop files here or If you choose to upload your Attorney Roster, please ensure the following information is included for each attorney. Full Name Year bar exam was passed States where attorney is admitted Hours worked per week Date the attorney joined the firm Retroactive Date (if different than date of hire) Insurance HistoryCheck here if you are not currently insured I am not currently insured Expiration Date* Current CarrierLimits*$100,000/$300,000$250,000/$500,000$250,000/$750,000$500,000/$500,000$500,000/$1,000,000$500,000/$1,500,000$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$5,000,000+/$5,000,000+Deductible$1,000$2,500$5,000$10,000$15,000$20,000$25,000$50,000Expiring PremiumWhy do we ask for your premium?Renewal Premium (if known)Optional Coverages Title Agency Claim Expenses Outside Limit (CEOL) First Dollar Defense Is your firm currently insured for cyber liability?YesNoClaim HistoryIn the past 5 years, have there been any claims/incidents/grievances against Applicant or member/past member of the firm or predecessor Firm? **YesNoIf yes, please upload any available claim documentation to our secure server. Drop files here or Please provide a brief summary (including any payments).Areas of PracticePlease enter the % of gross billings from each area of practice. Percentages must total 100%. Administrative Law – GeneralAdmiralty/MaritimeAdoptionAntitrust/Trade RegulationArbitration/MediationBanks/Savings and LoansBusiness Contracts and TransactionsCivil Rights and DiscriminationCivil LitigationPlaintiffCivil LitigationDefenseClass Action/Mass Torts – DefenseClass Action/mass Torts - PlaintiffCollection/RepossessionCommercial LawCommunicationsConstruction LawCorporate Organization/FormationDivorceWith client asset values Less than $1 millionDivorceWith client asset values $1 million to $5 millionDivorceWith client asset with values Greater than $5 millionElder LawEntertainmentGeneral Corporate/BusinessHealthcareImmigration and NaturalizationInsurance Defense litigationInternational LawIntellectual PropertyCopyright/TrademarkIntellectual PropertyPatentJuvenileLabor RelationsLocal Government Law/MunicipalMergers and AcquisitionsOil and GasPension and Employee BenefitsPersonal Injury other than MedMal – DefensePersonal Injury other than MedMal – PlaintiffPersonal Injury MedMal – DefensePersonal Injury MedMal – PlaintiffPublic UtilitiesReal EstateCommercialReal EstateResidentialReal EstateForeclosureReal EstateLand Use and ZoningReal EstateTitleSecurities LawSocial SecurityTaxationWills, Trusts, EstatesWith client asset values Less than $1 millionWills, Trusts, EstatesWith client asset values $1 million - $5 millionWills, Trusts, EstatesWith client asset values Greater than $5 millionWorkers’ Compensation LitigationPlaintiffWorkers’ Compensation LitigationDefenseOtherTOTALInternal ControlsDoes the firm have a conflict avoidance system?*YesNoDoes the firm regularly use engagement/declination letters (When Applicable)?YesNoAre there 2 calendars to track important dates?*YesNoHow many suits for fees have you filed against your clients in the last 2 years?*Number of non-Attorney Employees?*Number of Attorneys planning to retire within the next 3 years?*No coverage is bound or implied by submitting information via this form. Premium estimates provided from information on this form are only anticipated pricing and non-binding indications. Actual quotes are subject to completion and acceptance of a new business application with supplements (if applicable) and underwriting approval. Estimates may fluctuate based on information provided to us in your application . If you agree to the terms, click "I Agree" below.* I Agree
