Get a Quote "*" indicates required fields Basic InformationFirm Name:* Contact:* Address:* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone*Email* Website* Current CoverageExpiration Date:* MM slash DD slash YYYY Current Carrier:* Current Limits:* Deductible:* Current Premium:* Date Firm Established:* MM slash DD slash YYYY Prior Acts Date:* MM slash DD slash YYYY Personnel InformationList all Lawyers*Include yourself if you are a sole proprietorLawyer's NamePositionDate of HireDate First AdmittedStates AdmittedRetroactive (Prior Acts) Coverage Sole ProprietorPartnerOfficer/Director/ShareholderEmployed LawyerOf CounselIndependent Contractor Add RemoveFor each Of Counsel and Independent Contractor, indicate average hours worked per week for the applicant firm and if the attorney has separate malpractice coverage.Area of Practice InformationProvide the percentage of gross revenue. Must total 100%.Administrative LawPlease enter a number from 0 to 100.AdmiraltyPlease enter a number from 0 to 100.Antitrust / TradePlease enter a number from 0 to 100.Civil Rights / DiscriminationPlease enter a number from 0 to 100.Collection / BankruptcyPlease enter a number from 0 to 100.Commercial and Business Litigation – DefensePlease enter a number from 0 to 100.Commercial and Business Litigation – PlaintiffPlease enter a number from 0 to 100.Construction LawPlease enter a number from 0 to 100.Consumer LawPlease enter a number from 0 to 100.Corporate and Business TransactionsPlease enter a number from 0 to 100.CriminalPlease enter a number from 0 to 100.Employment Law – DefensePlease enter a number from 0 to 100.Employment Law – PlaintiffPlease enter a number from 0 to 100.Entertainment / SportsPlease enter a number from 0 to 100.Environmental LawPlease enter a number from 0 to 100.Estate / Probate / TrustPlease enter a number from 0 to 100.Family LawPlease enter a number from 0 to 100.Financial InstitutionPlease enter a number from 0 to 100.Financial PlanningPlease enter a number from 0 to 100.Government Contracts / RelationsPlease enter a number from 0 to 100.HealthcarePlease enter a number from 0 to 100.Immigration and NaturalizationPlease enter a number from 0 to 100.Insurance, Excluding Coverage OpinionsPlease enter a number from 0 to 100.Insurance, Coverage OpinionsPlease enter a number from 0 to 100.Intellectual Property – Patent / TrademarkPlease enter a number from 0 to 100.Intellectual Property – CopyrightPlease enter a number from 0 to 100.International LawPlease enter a number from 0 to 100.Labor Management RepresentationPlease enter a number from 0 to 100.Labor Management Labor RepresentationPlease enter a number from 0 to 100.LobbyingPlease enter a number from 0 to 100.Mediation / ArbitrationPlease enter a number from 0 to 100.Mergers and AcquisitionsPlease enter a number from 0 to 100.Natural Resources / Title and Title OpinionsPlease enter a number from 0 to 100.Natural Resources / All Other ServicesPlease enter a number from 0 to 100.Pension and Employee BenefitsPlease enter a number from 0 to 100.Personal Injury and Negligence – DefensePlease enter a number from 0 to 100.Personal Injury and Negligence – PlaintiffPlease enter a number from 0 to 100.Plaintiff – Class ActionPlease enter a number from 0 to 100.Plaintiff – Mass TortPlease enter a number from 0 to 100.Real Estate / Title Agent – ResidentialPlease enter a number from 0 to 100.Real Estate / Title Agent – CommercialPlease enter a number from 0 to 100.Securities Law (incl. bonds, private placements, and ltd. partnerships)Please enter a number from 0 to 100.Taxation – OpinionsPlease enter a number from 0 to 100.Taxation – OtherPlease enter a number from 0 to 100.Workers Compensation – DefensePlease enter a number from 0 to 100.Workers Compensation – PlaintiffPlease enter a number from 0 to 100.OtherPlease enter a number from 0 to 100.Other (Please elaborate) Total*Must equal 100%Additional InformationDo you use a computerized docket/calendar platform with software designed for a law firm?* Yes No Do you have a computerized case management system?* Yes No Engagement:* Engagement for all new clients Engagement for new matters/existing clients Non-engagement Disengagement Conflict of interest:* Computer Index File Conflict Committee Memory Only Fee suits in the past year:*Number of full time non-attorney support staff:*Number of part time non-attorney support staff:*Wholly owned Title Agency or mediation / arbitration firm to be included in coverage?* Yes No Claim/suit in past five years?* Yes No Potential claim?* Yes No Pending disciplinary or any disciplinary finding?* Yes No Prior non-renewal, declination or cancellation?* Yes No Limits requested:* Deductible requested:* SignedOwner, Officer or Partner* Title* Date* MM slash DD slash YYYY
