Premium Query
LAWYERS PROFESSIONAL LIABILITY

General Firm Information

Firm Name * Contact Name *	Business Phone Number Business Fax Number
Principle Business Address (No P.O. Boxes)	E-mail Address *
City  County  State  ZIP Website Address	Effective Date Requested Date Firm was established

Attorney Information

1.	List all attorneys, including yourself, to be insured. "Of Counsel" attorneys must be listed if coverage is desired. (More than five attorneys, please add in "Further Information".

Attorney Name	D.C. * (See Below)	Yrs in Practice	Date of Hire	# Hrs Worked / Week	Individual Attorney RetroDate

*DC Designation Codes O - Officers, Directors, Shareholders of the corporation who are licensed attorneys P - Partners if a Partnership PT - Part-time Lawyers (must practice law fewer than 26 hours per week solely for applicant firm)

IC - Independent Contractor S - Sole Proprietor E - Employed Attorneys C - Of Counsel attorney

 

2.	a. During the past five (5) years, has any attorney named in Question 1 had coverage declined, canceled or non-renewed by any professional insurer? If Yes, please explain.	No Yes
	b. During the past five (5) years, has any attorney named in Question 1 been the subject of a reprimand, disciplinary action or current investigation? If Yes, provide a copy of such action.	No Yes
	c. During the past five (5) years, has any professional liability claim or suit been made against any attorney named in Question 1, OR is any attorney aware of any circumstances, incidents, acts, errors, or omissions which could result in a professional liability claim against the firm, any attorney of the firm, or its predecessors? If Yes, provide full details on a Supplemental Claim Information Form.	No Yes

 

3.

Do all attorneys listed in Question 1 meet state Continuing Legal Education (CLE) Requirements? If CLE is not required in your state, check N/A.

No Yes N/A

 

4.

Does the firm handle any Class Action or Mass Tort Cases?

No Yes

 

5.

The Firm has a retroactive date of:

 

6.

Does the Applicant's practice involve any Attorney acting in the capacity of a mediator or arbitrator? If Yes, indicate the percentage of time devoted to acting as a mediator or arbitrator:

No Yes

 

Your Insurance Coverage Information

 

7.

Provide Current Policy information below:   (If NO CURRENT policy, please check the box.)

None

 

Inception (mm/dd/yyyy)
Expiration(mm/dd/yyyy)
Insurance Carrier
Policy Number
Limits
Deductible
Premium

Nature of Practice

8. Areas Of Practice Based upon the number of hours devoted to each category.

 

Area of Practice	%	Area of Practice	%
Admiralty/Marine		Government (Federal/State/Local/Lobbying)
Antitrust/Trade Regulation		Healthcare
Aviation		Immigration
Bankruptcy		Insurance Defense Litigation
Business Transactions / Commercial Law		Insurance Other (Coverage, Regulatory, Subrogation)
Civil Rights		International Law
Collections		Investment Counseling/ Money Management
Commercial Practice - Business Litigation		Labor - Union Related Work
Communications / Media		Medical Malpractice - Defendant
Construction Law		Medical Malpractice - Plaintiff
Consumer Claims		Oil / Gas
COPYRIGHT/TRADEMARK		PATENT
Corporate - Business Formation/Alteration		Personal Injury - Defendant
Corporate - Business Transactions/Advice		Personal Injury - Plaintiff
Criminal Law		Public Utilities
Disability / Social Security		Real Estate - Commercial
Elder Law		Real Estate - Residential
Employment		SECURITIES LAW (except corporate formation)
ENTERTAINMENT		Secured Transaction (UCC - Commercial Paper)
ENVIRONMENTAL		Taxation
Estates / Wills / Trust / Probate		Tax Shelters
Family Law		Workers' Compensation - Defendant
Financial Institutions-Reg. Compliance		Workers' Compensation - Plaintiff
		TOTAL (must equal 100%)

9. If the Applicant has stated any percentage of Medical Malpractice - Plaintiff work in the area of practice chart above, please indicate in percentages the amount of work allocated to the following areas?

Nursing Homes	%	OB/GYN	%
Oncology	%	Pediatrics	%
Permanent Disability	%	Wrongful Death	%
Other*	%

*If the Applicant stated a percentage of work for "Other," please explain the type of work performed in "Further Information" below.
 

Coverage Requested

The Firm would like a Premium Query for Limits and Deductible(s).

Optional Coverage Requested-Subject to Underwriting Review

We request Premium Queries including endorsements - if available - that provide the following optional coverage:

Claims Expenses Outside the Limits
Claims Expenses Partially Outside the Limits
An Aggregate Deductible
A Loss Only Deductible

Further Information

 

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