Secured by SSL

Attorneys Online Application


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Personal Information
First Name
Required
Last Name
Required
Company Owner
Required
Formal Name of Business
Required
Business Type
Required
Street
Required
City
Required
County
Required
State
Required
ZIP / Postal Code
Required
Primary Phone Number
Required
Please list all State(s) where the firm practices:
Required
Addresses of other office locations
Required
Do you share letterhead with another attorney?
Required
Do you share an office location with another attorney?
Required
Do you share cases with another attorney?
Required
Year Business Established
Required
Please list all areas of practice (Must add up to 100%. For example: Criminal 80%, Personal Injury 20%):
Required
How many years of experience do you have?
Required
If you are a sole practitioner, provide the name and address of who would handle your cases in the event of your incapacitation or vacation..
Required
Number of Employed Attorneys
Required
Number of Attorneys that are Of Counsel to Firm
Required
How many support staff members are in the firm?
Required
In the last 12 months, how many attorneys have left your firm?
Required
In the last 12 months, how many attorneys have joined your firm?
Required
How many attorneys does the firm plan to add in the next 12 months?
Required
In the last 12 months, how many non-attorneys have left your firm?
Required
Does any client or group of related clients make up 10% or more of the firm’s annual gross receipts?
Required
Does your firm accept any form of compensation other than legal fees?
Required
Does or has any firm member introduced clients to one another for investment purposes?
Required
Does the firm ever represent adverse but friendly parties in the same matter?
Required
Is the firm or any attorneys currently covered by an extended reporting period endorsement?
Required
Total firm billings for the current 12 month period.
Required
Total firm billings for the prior 12 months.
Required
For how many years has the firm been continuously insured for malpractice claims?
Required
Amount of Desired Insurance
Required
Do you currently have insurance?
Required
Current Policy End Date
Required
/ /
Prior Insurance
Required
Current Premium
Required
Current Insurance Provider
Required
Effective Date
Required
/ /
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?
Required
Do you have knowledge of any circumstance, act, error, or omission that could result in a professional liability claim?
Required
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?
Required
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?
Required
Have you ever had professional liability insurance cancelled or non renewed?
Required
Does the Applicant have any high-profile clients who are entertainers, sports figures or public officials?
Required
Has the firm been involved in any mass tort / class action cases within the past five years?
Required
Does the Applicant have discretionary investment authority for any clients?
Required
In the last five (5) years, has any attorney with the Applicant firm, represented any financial institution?
Required
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?
Required
Does any firm attorney serve as a director, officer, trustee (other than estate trusts), partner or employee of any client?
Required
Does any firm member exercise fiduciary control or possess any ownership interest in any client or any business venture with a client?
Required
Does your firm use engagement letters on all new matters?
Required
Does the engagement letter include the identity of the client?
Required
Does the engagement letter include the Scope of Representation that includes key terms of legal representation?
Required
Does the engagement letter include the Fee structures and billing agreements?
Required
Does the engagement letter include the Termination agreement that includes file retention and destruction terms?
Required
Does your firm require clients to sign engagement letters / agreements?
Required
Does your firm routinely use declination of representation letters?
Required
Does your firm routinely use termination of services letters?
Required
Does your firm routinely use file status update letters?
Required
Does your firm use any of the following conflict avoidance methods (check all that apply):
Required


Hold down the Ctrl Key to make multiple selections.
Does your firm update its conflict avoidance system at least weekly?
Required
Does your firm cross-check conflicts by predecessor, merged or acquired firms?
Required
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?
Required
Does your firm allow attorneys to enter into business with firm clients?
Required
Does your firm require disclosure if such relationships are permitted?
Required
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):
Required


Hold down the Ctrl Key to make multiple selections.
Does your firm maintain a calendar system using these methods (check all that apply):
Required


Hold down the Ctrl Key to make multiple selections.
Does your firm use two individuals to maintain its calendar system?
Required
Does your firm update its calendar system at least weekly?
Required
Does your firm place ultimate responsibility for calendar system with a firm lawyer?
Required
Does your firm have a formal procedures manual?
Required
Are all employees trained regarding firm policies and procedures?
Required
Are new attorneys supervised by a more senior attorney?
Required
Is support personnel work reviewed by an attorney prior to release to the client?
Required
Are all new matters reviewed prior to acceptance by firm management?
Required
Does firm management regularly review all ongoing matters?
Required
What percentage of accounts receivable are outstanding more than 90 days?
Required
How many times have you sued one of your clients for unpaid fees in the last 5 years?
Required
E-Mail Address
Required
How did you hear about us?
Optional
Additional Comments
Optional
Submission Validation
Required
CAPTCHA
Change the CAPTCHA codeSpeak the CAPTCHA code
 
Enter the Validation Code from above.
Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
Location
Mailing Address Only
P.O. Box 868
Oakhurst, NJ 07755
Facebook Twitter LinkedIn Google Maps
© Copyright 2020. All rights reserved.
Powered by Insurance Website Builder