Zolofra Insurance
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Toll Free: (888) 858-1777
Fax: (732) 334-0405
Email: Ben@zolofrainsurance.com





Name of Firm (as it should appear on the policy)

Contact Person

Street Address

City

County

State

Zip Code

Telephone Number

Fax Number

Email Address

If you have multiple office locations, please list each location here.

Type of formation:


Year Firm Established

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


Do you have more than one office location?


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?


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?


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?


Does the Applicant have discretionary investment authority for any clients?


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


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?


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?


Require clients to sign engagement letters / agreements?


Use any of the following conflict avoidance methods:

 Oral/Memory? Computer? Conflict Committee? Index File

Update its conflict avoidance system at least weekly?


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


Insist on obtaining a written waiver from its clients in order to perform on-going services when a 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:

 Single Calendar Dual Calendar Tickler cards Computer Master Listing

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?


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)?


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


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%):

How did you hear about us?


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.

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 ben@zolofrainsurance.com. 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!

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Zolofra Insurance Agency
P.O. Box 8787
Red Bank, NJ 07701
Toll Free: (888) 858-1777
Direct: (732) 542-1757
Fax: (732) 334-0405
Email: Ben@zolofrainsurance.com
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