Docstoc

Lawyers Professional Liability Premium Indication Form Premium

Document Sample
Lawyers Professional Liability Premium Indication Form Premium Powered By Docstoc
					                                                 Premium Indication Form
For a quote, fax to 630-718-3504               Questions: Call Chris Rigdon at 800-972-4407                         www.cdrigdon.com

Firm Name: ___________________________ Firm Contact Person: ______________________________
Street Address: _______________________________________________ Web Site Address: _______________
Cit/State/Zip: _________________________________________________ County: _______________________
Contact Email Address: _______________________ Phone: ___________________ Fax: __________________
                                                   To receive a quote all questions must be answered
       Areas of Practice
____ % Administrative                                                                            ____ % Other Plaintiff____________________
____ % Bankruptcy                       ____ % Medical Malpractice                               ____ % Civil Rights- Plaintiff
____ % Collections                      ____ % Products Liability                                ____ % Banking Services- loan documentation
____ % Commercial & Corp Lit-Defense    ____ % Class Action                                      ____ % Banking Services excluding loan documentation
____ % Commercial & Corp Lit- Plaintiff ____ % PI or BI Plaintiff- Other                         ____ % Environmental
____ % Corporate Formation/ Alteration   ____ % Real Estate- Residential                         ____ % Labor Union Representation
____ % Criminal                          ____ % Real Estate- Commercial                          ____ % SEC/ State Securities
____ % ERISA or Employee Benefits        ____ % Real Estate- Title                               ____ % Entertainment, Sports or Celebrity
____ % Family Law- Excluding Divorce     ____ % Taxation- Individual                             ____ % Investment Counseling/ Money Management
____ % family Law- Divorce Only          ____ % Taxation- Commercial                             ____ % Mergers/ Acquisitions
____ % Immigration                       ____ % Other Defense ______________                      ____ % Oil, Gas or Mining
____ % Labor Management Representation ____ % Admiralty/Maritime                                 ____ % Patent/Copyright/Trademark
____ % Mediation/ Arbitration            ____ % Wills/Estate/Probe/Trust                         ____ % Real Estate Syndication/ Limited Partnership
____ % Personal or Bodily Injury         ____ % Workers Compensation – Defense                   ____ % Other _________________________________
                                                                                                 100 % Total Describe on separate sheet, if necessary
Current Carrier Information
Carrier ______________________________________________ Expiration Date ___________________ Retroactive Date _____________________
Limits of Liability ______________________________________ Deductible __________ Per Claim OR ___________ Per Aggregate
Additional Claim Expense Limit ______ Yes _____ No           First Dollar Defense ____ Yes ____ No
Premium ________________________            Includes Career Coverage ____ Yes ____ No
Attorney Names                                 Designation                               Date Admitted to Bar              Hours Worked Per Week
                                               O= Owner; P= Partner; E= Employee
                                                      O/C= Of Counsel
_________________________________     ________________________            ____________________  ______________________
_________________________________     ________________________            ____________________  ______________________
_________________________________     ________________________            ____________________  ______________________
_________________________________     ________________________            ____________________  ______________________
Number of Support Staff _____________  Number of Lawyers who have attended CLE ________________
________________________________________________________________________________________________________________________
Number of suits for fees filed in the past two years __________          Date firm Established______________________
Docket Type ___Computer ___Tickler ___Two Calendars ___ Daytimer ___Other_____________________________
Is your docket maintained by at least two people? ____ Yes ____ No
How frequently is your docket cross-checked? ____ Daily ____ Weekly ____ Bi Weekly ____ Monthly
Conflict Type ____ Computer ____ Single Index ____ Multi-Index ____ Oral/Memory ____ Other __________________
If a sole practitioner, do you have a back up attorney? ____ Yes ____ No
Do you use Engagement Letters ____ Yes ____ No Fee Agreements ____ Yes ____ No Declination Letters ____ Yes ____ No
Does any attorney in the firm serve as a director, officer, or employee of any client of the firm? ____ Yes ____ No
Does any attorney hold an equity interest in any client’s business? ____ Yes ____ No                   If yes please provide details on second page
Does any single client represent 10% or more of your firm’s total gross billings? ____ Yes ____ No If yes please provide details on second page
Has any member of the firm been disbarred, reprimanded, suspended,
had license revoked of had any complaint or disciplinary action?                    ____ Yes ____ No If yes please provide details on second page
Over the last five years, has any attorney of the firm (past or present) had a
Malpractice claim filed against them or reported an incident or circumstances
to a malpractice carrier?                                                           ____ Yes ____ No If yes please provide details on second page
                                    Please attached a copy of the firm letterhead and any advertisements
                This form is for estimate purposes only. Coverage may be bound only upon submission and acceptance of a completed application

Attorney Signature ________________________________________                              Date _______________________________________

				
DOCUMENT INFO
Shared By:
Categories:
Stats:
views:24
posted:12/23/2010
language:English
pages:1
Description: Lawyers Professional Liability Premium Indication Form Premium