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Complete and submit the application below to request a free, no-obligation quote on your firm's Professional Liability insurance:

Firm Information
 
Firm name
Firm phone number
Firm fax number
Email address
 
Firm Mailing Address
 
Firm address 1
Firm address 2
City
County
State
Zip Code
 
Contact Information
 
Contact name
Contact phone number
Best time to contact
 
Current Coverage Information
 
Current Carrier
Current Premium
Current Professional Liability Expiration Date
# Years Continuous Coverage
Prior Acts Retroactive Date N/A mm/yyyy
Current Limits
Current Deductibles

Deductible Type

 
Areas of Practice
 
Please provide a percentage of gross revenue for all areas of practice:
%
%
%
%
%
%
%
%
%
%
Total must equal 100%
     
Has the firm or any individual lawyer been the subject of a professional liability Claim in the last five years?
Yes No
Is the firm's primary time/docket control system computerized?
Yes No
How many additional time/deadline controls are used by the lawyers or support staff (i.e. attorney calendar, secretary calendar, dead line lists, PDA's, legal assistant calendars, etc.)?
Is the firm's conflict of interest system computerized?
Yes No
Does the firm use standard engagement letters, declination letters, change in scope of representation letters, withdrawal letters as needed for non-transactional representations?
Yes No
Does the firm ever file a law suit against a client to collect outstanding fees?
Yes No

If yes, how many in the past 12 months?





 

 
   
 
Insurance Program Administered by Lockton Risk Services