Name of Firm (as it should appear on the policy)
Street Address (no PO Boxes)
Is this the location where the firm meets with clients?
Is this location a work-at-home or Virtual Office Arrangement?
If this is a work-at home or Virtual Office Arrangement, please advise where the firm meets with clients:
How many attorney (including principles) are in the firm?:
How many support staff members are in the firm?:
For discount purposes, provide any State Bar Association you belong to along with your Membership number here:
Please list all State(s) where the firm practices:
Type of formation:
Year Firm Established
For how many years has the firm been continuously insured for malpractice claims?
What date do you want this coverage to start?
Which malpractice limit of insurance are you seeking?
Please Select100,000 / 300,000250,000 / 500,000500,000 / 500,000500,000 / 1,000,0001,000,000 / 1,000,0001,000,000 / 2,000,0002,000,000 / 2,000,000
Which malpractice deductible are you seeking?
Which optional coverages are you seeking?
First Dolalr Defense Aggregate Deductible Claim Expenses Outside the Limit None
Has the firm merged with or acquired any firms in the last 3 years?
Do you have more than one office location?
Do you share an office location with another attorney?
Do you share letterhead with another attorney?
Do you share cases with another attorney?
If you have more than 1 office location, share and office location, letterhead or cases with another attorney, provide details below in the comments box. Alternatively, you can fax an explanation on your letterhead to us at 732.542.1757 or email to email@example.com
In the last 12 months, how many attorneys have left your firm?
In the last 12 months, how many attorneys have joined your firm?
How many attorneys does the firm plan to add in the next 12 months?
In the last 12 months, how many non-attorneys have left your firm?
If your firm uses any attorneys not listed on this application to provide legal services, please advise name of each attorney here:
If you do not currently carry E&O Insurance, please advise why (to explain to the underwriters).
If any professional liability insurance for the applicant, or any member of the applicant firm ever been declined or cancelled, refused to be renewed or accepted only on special terms please advise why (to explain to the underwriters).
Does any client or group of related clients make up 10% or more of the firm’s annual gross receipts?Please SelectYesNo
If yes, provide name of group (s) or client(s) here with percentage of annual gross receipt for each:
Does your firm accept any form of compensation other than legal fees?
Does or has any firm member introduced clients to one another for investment purposes?
Does the firm ever represent adverse but friendly parties in the same matter?
Name of Current Carrier (if none, state NONE)
Current policy term (mm/dd/yyyy)
Current Limits of Liability
Retroactive Date (mm/dd/yyyy)
Expiring Premium, if you do not carry this coverage currently, state NONE
Is the firm or any attorneys currently covered by an extended reporting period endorsement?
For each attorney please provide the following:
1. Name of attorney:
2. States Admitted In:
3. Year First Admitted to Bar:
4. Years in practice:
5. Date joined firm:
6. Avg. # of hours/week:
7. Avg. # of CLE hours/year:
8. Status (Owner/Partner/Member/Counsel/Employed Lawyer/Independent Contractor):
If you are a sole practitioner, who handles your cases in the event of your incapacitation or vacation? Please Note: If a policy is issued in reliance upon this application, it shall not apply to the aforementioned attorney.
If applying as a Sole Practitioner for Part Time Coverage, are you employed in any capacity other than working as a Part Time Lawyer as applied for herein?
Total firm billings for the prior 12 months.
Total firm billings for the current 12 month period.
Has any professional liability claim or suit been made in the past five years against the firm or its predecessor or any current or former members of the firm or it’s predecessor firm(s) in the past five years?
Do you have knowledge of any circumstance, act, error, or omission that could result in a professional liability claim?
During the past ten years has any attorney mentioned here or any employee of the Applicant been the subject of a criminal action, reprimand, disciplinary action, bar complaint, investigation or other ethics proceeding? If yes, please explain below.
Has any member of the firm ever been refused admission to practice, disbarred, suspended, fined or held in contempt by any court or local bar association?
Have you ever had professional liability insurance cancelled or non renewed?
Does the Applicant have any high-profile clients who are entertainers, sports figures or public officials?
Has the firm been involved in any mass tort / class action cases within the past five years?
Does the Applicant have discretionary investment authority for any clients?
Please SelectYes and one client accounts for more than $500,000Yes and any one client does NOT account for more than $500,000No
In the last five (5) years, has any attorney with the Applicant firm, represented any financial institution?
Has the Firm or any lawyer in the Firm represented publicly traded clients with
services rendered involving Sarbanes-Oxley Act (SOX) compliance including
but not limited to Securities, Accounting, Financial/Investment Services or Tax work?
Does any firm attorney serve as a director, officer, trustee (other than estate trusts), partner or employee of any client?
Does any firm member exercise fiduciary control or possess any ownership interest in any client or any business venture with a client?
Does your firm use engagement letters on all new matters?
Does the engagement letter include the identity of the client?
Does the engagement letter include the Scope of Representation that includes key terms of legal representation?
Does the engagement letter include the Fee structures and billing agreements?
Does the engagement letter include the Termination agreement that includes file retention and destruction terms?
Does your firm require clients to sign engagement letters / agreements?
Does your firm routinely use declination of representation letters?
Does your firm routinely use termination of services letters?
Does your firm routinely use file status update letters?
Does your firm use any of the following conflict avoidance methods (check all that apply):
Oral/Memory Computer Conflict Committee Index File
Does your firm update its conflict avoidance system at least weekly?
Does your firm cross-check conflicts by predecessor, merged or acquired firms?
Does your firm insist on obtaining a written waiver from its clients in order to perform on-going services when a actual/potential conflict exists?
Does your firm allow attorneys to enter into business with firm clients?
Does your firm require disclosure if such relationships are permitted?
If the firm uses a computerized system to manage its docket and scheduling demands, please indicate which of the following describes that system (check all that apply):
Updated daily Centralized / Firm wide All branch offices integrated Monitored by multiple indviduals Tracks statues of limitations Data backed up / stored offsite
Does your firm maintain a calendar system using these methods (check all that apply):
Single Calendar Dual Calendar Tickler cards Computer Master Listing
Does your firm use two individuals to maintain its calendar system?
Does your firm update its calendar system at least weekly?
Does your firm place ultimate responsibility for calendar system with a firm lawyer?
Does your firm have a formal procedures manual?
Are all employees trained regarding firm policies and procedures?
Are new attorneys supervised by a more senior attorney?
Is support personnel work reviewed by an attorney prior to release to the client?
Are all new matters reviewed prior to acceptance by firm management?
Does firm management regularly review all ongoing matters?
What percentage of accounts receivable are outstanding more than 90 days?
How many times have you sued one of your clients for unpaid fees in the last 5 years?
Please list all areas of practice (Must add up to 100%. For example: Criminal 80%, Personal Injury 20%):
How did you hear about us?
Please SelectGoogleTwitterFacebookLinkedInLawyers Diary and ManualOther Trade PublicationEmailPostcardNewspaper ADFriendTrade ShowOther
Disclaimer Notice – The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.
Please utilize the “Send” Button to send your form to our office. If the website does not allow you to submit the form, please print the page and fax it to 732.334.0405 or scan it into your computer and send it to firstname.lastname@example.org. Do not “Refresh” the page because all data entered onto the form will be lost.
After you hit the “Send” button, please scroll back down to this area and if successfully sent, a message will appear below. If not successfully sent, a message will appear below which means you have to scroll back up and complete the missing information, which typically involves entering information into a highlighted box. Complete the missing information and then hit “Send” again. Thank you!
Your First Name (required)
Your Last Name (required)
Your Email (required)
Re-Enter Your Email (required)
Name Of Your Company or type of business if seeking commercial insurance (required)
Street Address (required)
Zip Code (required)