Quote Test

Name of current professional liability insurer (write "none" if you currently have no professional liability coverage)

Applicant Name*

List All of Applicants Addresses*

City*

State*

ZIP*

Firm Phone Number*

Firm Email Address*

Firm Website Address

Date Firm was Established*

Current Year*

Previous Year*

Estimate the percentage of hours per year the firm works in each area of practice (NOTE: Must total 100%)

Number of lawyers of the Applicant to be covered under this policy

Number of non-lawyer employees of the applicant

Does the firm have formal, written procedures regarding the maintenance of custodial accounts?
YesNo

Fee Suits: Have you filed any suits for collection of delinquent fees in the past two years?*
YesNo

>Does the firm outline and reduce to writing its billing policy and procedures when agreeing to represent a new client?*
YesNo

Does the firm use scope of service letters when taking on new matters for existing clients?*
YesNo

Engagement Letters:
%

Termination Letters (documenting when a matter has been completed)
%

Disengagement Letters (documenting when the firm withdraws from a matter)
%

Non-Engagement Letters (documenting when the firm declines to accept a matter)
%

N/A

Back Up Lawyer:

Address, City, State:

Telephone Number:

Agreement Expiration Date:

a. Currently pending investigations/proceedings
YesNo

b. Reprimand or Censure
YesNo

c. Suspension
YesNo

d. Imposition of a fine
YesNo

e. Refusal of admission to the bar or any bar association, court or administrative agency
YesNo

In the past five (5) years, has any professional liability claim been made or suit brought against the firm, any predecessor firm, or any member of the firm?
YesNo

If "Yes", please put in details including number of suits, nature of complaint and name of claimants.

Value of Business Personal Property Owned (Furniture, computers, etc.)

Do you own your own building?
YesNo

Year Built

Square footage

Number of Employees

FEIN (tax id #)