Lawyers Online Application

Name of Firm

Contact Person

Street Address

City

State

Zip Code

Telephone Number

Fax Number

Email Address

Type of formation:


Please Select Proprietorship Partnership Corporation Association LLP LLC Other

Year Firm Established

Has the firm merged with or acquired any firms in the last 3 years?


Please Select Yes No

Do you have more than one office location?


Please Select Yes No

Name of Current Carrier (if none, state NONE)

Current policy term (mm/dd/yyyy)

Current Limits of Liability

Current Deductible

Retroactive Date (mm/dd/yyyy)

Expiring Premium, if you do not carry this coverage currently, state

Is the firm or any attorneys currently covered by an extended reporting period endorsement?


Please Select Yes No

Current total number of non-lawyer employees

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 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?


Please Select Yes No

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?


Please Select Yes No

Do you have knowledge of any circumstance, act, error, or omission that could result in a professional liability claim?


Please Select Yes No

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.


Please Select Yes No

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?


Please Select Yes No

Have you ever had professional liability insurance cancelled or non renewed?


Please Select Yes No

Does the Applicant have any high-profile clients who are entertainers, sports figures or public officials?


Please Select Yes No

Does the Applicant have discretionary investment authority for any clients?


Please Select Yes and one client accounts for more than $500,000 Yes and any one client does NOT account for more than $500,000 No

In the last five (5) years, has any attorney with the Applicant firm, represented any financial institution?


Please Select Yes No

Does any firm attorney serve as a director, officer, trustee (other than estate trusts), partner or employee of any client?


Please Select Yes No

Does any firm member exercise fiduciary control or possess any ownership interest in any client or any business venture with a client?


Please Select Yes No

How many suits for the collection of fees have been filed against clients in the past 5 years?

Use engagement letters on all new matters?


Please Select Yes No

Require clients to sign engagement letters / agreements?


Please Select Yes No

Use any of the following conflict avoidance methods:


 Oral/Memory?
 Computer?
 Conflict Committee?
 Index File

Update its conflict avoidance system at least weekly?


Please Select Yes No

Cross-check conflicts by predecessor, merged or acquired firms?


Please Select Yes No

Insist on obtaining a written waiver from its clients in order to perform on-going services when a actual/potential conflict exists?


Please Select Yes No

Allow attorneys to enter into business with firm clients?


Please Select Yes No

Require disclosure if such relationships are permitted?


Please Select Yes No

Maintain a calendar system using these methods:


 Single Calendar
 Dual Calendar
 Tickler cards
 Computer
 Master Listing

Use two individuals to maintain its calendar system?


Please Select Yes No

Update its calendar system at least weekly?


Please Select Yes No

Place ultimate responsibility for calendar system with a firm lawyer?


Please Select Yes No

If you are a sole practitioner, have you designated a lawyer(s) who will be responsible for your affairs if you are absent for an extended period of time (i.e. vacation, etc)?


Please Select Yes No

Does any single client account for more than twenty-five percent (25%) of the firm’s gross annual billings?


Please Select Yes No

How many times have you sued a client for unpaid fees in the last 5 years?

Areas of practice (Please List, Must add up to 100%):

Additional Comments:

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.

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