Indication Proposed Effective Date: 12:01 a.m. Standard Time at the address of the Applicant.From*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920To*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Are you currently insured? Yes No I. GENERAL INFORMATION1. Applicant* 2. Address* Street Address County City State / Province / Region ZIP / Postal Code 3. Telephone Number:*Contact Person* Email* II. APPLICANT’S PRACTICE1. Practice Areas Describe the Applicant’s practice by showing the approximate percentage of gross billable dollars during the past year derived from the following: Total of all categories must equal 100% CATEGORY AAdministrativePlease enter a number from 0 to 100.AppellatePlease enter a number from 0 to 100.ArbitrationPlease enter a number from 0 to 100.CriminalPlease enter a number from 0 to 100.ImmigrationPlease enter a number from 0 to 100.MediationPlease enter a number from 0 to 100.Municipal LawPlease enter a number from 0 to 100. CATEGORY BGovernment LawPlease enter a number from 0 to 100.Title/CommercialPlease enter a number from 0 to 100.Title/ResidentialPlease enter a number from 0 to 100.TrafficPlease enter a number from 0 to 100. CATEGORY CInternational LawPlease enter a number from 0 to 100.JuvenilePlease enter a number from 0 to 100.Labor/ Management RepresentationPlease enter a number from 0 to 100. CATEGORY D - Litigation:Plaintiff: BI/PIPlease enter a number from 0 to 100.Plaintiff: Class Action or Mass TortPlease enter a number from 0 to 100.Plaintiff: Medical MalpracticePlease enter a number from 0 to 100.Plaintiff: Other LitigationPlease enter a number from 0 to 100.Defense: Class ActionPlease enter a number from 0 to 100.Defense: InsurancePlease enter a number from 0 to 100.Defense: (Excluding Med Mal)Please enter a number from 0 to 100.Defense: Medical MalpracticePlease enter a number from 0 to 100.Defense: Other BI/PIPlease enter a number from 0 to 100.Defense: Other LitigationPlease enter a number from 0 to 100. CATEGORY ECivil RightsPlease enter a number from 0 to 100.Foreign LawPlease enter a number from 0 to 100.GuardianshipsPlease enter a number from 0 to 100. CATEGORY FAdmiraltyPlease enter a number from 0 to 100.AntitrustPlease enter a number from 0 to 100.BankingPlease enter a number from 0 to 100.Commercial LawPlease enter a number from 0 to 100.Corporate FormationPlease enter a number from 0 to 100.ForeclosuresPlease enter a number from 0 to 100.General Corporate AdvicePlease enter a number from 0 to 100.LobbyingPlease enter a number from 0 to 100.Tax PreparationPlease enter a number from 0 to 100. CATEGORY GBankruptcyPlease enter a number from 0 to 100.CollectionPlease enter a number from 0 to 100.ConstructionPlease enter a number from 0 to 100.Estate PlanningPlease enter a number from 0 to 100.Estate, Trust, WillsPlease enter a number from 0 to 100.Family LawPlease enter a number from 0 to 100.Patent,Trademark, Copyright LitigationPlease enter a number from 0 to 100.Tax OpinionsPlease enter a number from 0 to 100. CATEGORY HEntertainmentPlease enter a number from 0 to 100.FiduciaryPlease enter a number from 0 to 100.Investment CounselingPlease enter a number from 0 to 100.Labor/Union RepresentationPlease enter a number from 0 to 100.Mergers/Acquisitions (Corporate)Please enter a number from 0 to 100.Purchase/sale of businessPlease enter a number from 0 to 100. CATEGORY IAdoptionsPlease enter a number from 0 to 100.Environmental LawPlease enter a number from 0 to 100.High Profile Divorce (greater than 10 Million Marital Assets)Please enter a number from 0 to 100.Limited Partnership FormationPlease enter a number from 0 to 100.Oil/Gas/MiningPlease enter a number from 0 to 100.Real Estate DevelopmentPlease enter a number from 0 to 100. CATEGORY JReal Estate SyndicationPlease enter a number from 0 to 100.Securities / BondsPlease enter a number from 0 to 100. CATEGORY KReal estate closings/generalPlease enter a number from 0 to 100. CATEGORY LTribal LawPlease enter a number from 0 to 100.Patent, Trademark, Copyright Prosecution or SearchesPlease enter a number from 0 to 100.Water LawPlease enter a number from 0 to 100. Total Gross %2. ATTORNEYSA) Please list the number of all attorneys in categories below as an expression of the number of years employed by the Applicant Firm. Less than 1 yearPlease enter a number greater than or equal to 0.1 yearPlease enter a number greater than or equal to 0.2 yearsPlease enter a number greater than or equal to 0.3 yearsPlease enter a number greater than or equal to 0.4 yearsPlease enter a number greater than or equal to 0.5 years+Please enter a number greater than or equal to 0.TOTAL* Do you have any attorneys working less than 20 hours per week?* Yes No B) Total “Of Counsel” or Independent Contractors*Include only “Of Counsels” or IC’s who average working for you 20 hours or less per week.. (Otherwise, include in Category A.)3. CURRENT COVERAGE If not currently insured, indicate the desired limits and deductions.a. Insurance Company b. Expiration DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Retroactive Date (If applicable)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920c. PremiumLimit*Deductible*4. CLAIMS/CIRCUMSTANCES/DISCIPLINARYa. Has any professional liability claim or suit been made in the past five (5) years against the firm or its predecessor firm (s) or any current or former member of the firm or its predecessor firm(s)?* Yes No TOTAL NO. OF CLAIMSb. After inquiry, does any firm member know of any circumstance, situation, act, error or omission that could result in a professional liability claim or suit against the firm or its predecessor firm(s) or any of the current or former members of the firm or its predecessor firm(s)?* Yes No TOTAL NO. OF CIRCUMSTANCESIf “Yes” to a. or b., please attach a copy of the Claim Supplement you completed for your current Insurer and update as needed. Also, forward 5 year loss runs if available.c. Has any current or former member of the firm ever been refused admission to practice, disbarred, suspended, fined or held in contempt by any court, state or local bar association, administrative agency or regulatory body?* Yes No If “Yes,” please provide full details.5. SUITS FOR FEESa. How many suits for collection of fees have been filed against firm clients in the last two (2) years?*If none, enter zero.6. ADMINISTRATIVE CONTROLSa. Do you maintain a Docket Control System with at least two Independent date controls?* Yes No b. Is it computerized?* Yes No c. Do you maintain a Conflict of Interest Avoidance System?* Yes No d. Is it computerized?* Yes No e. Do you utilize engagement letters for all clients?* Yes No This form will be used to provide your firm with an estimate of premium cost. Coverage can only be bound after an application form is completed and accepted by the Company.
