Lawyers' Professional Liability Questionnaire

Please try to answer all questions to the best of your ability. This form will allow us to provide you with a few preliminary quotes based on your firm's specifics.

Contact Person*

First NameLast NameSuffix

E-mail*

Firm Name*

# Attorneys

Phone*

Fax

Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please provide a copy of your firm's current letterhead.

Upload a File

	Percentage
Abstracting/Title
Administrative Law
Admiralty/Maritime – Defense
Admiralty/Maritime – Plaintiff
Ad Valorem Tax
Antitrust/Trade Regulation
Aviation
Bankruptcy
Bonds
Business Transaction/Commercial Law - Defense
Business Transaction/Commercial Law - Plaintiff
Civil Rights/Discrimination
Class Action - Plaintiff
Collection
Commercial/Business Litigation - Defense
Commercial/Business Litigation - Plaintiff
Communication (FCC)
Communications/Media
Construction Law/Building Contracts
Consumer Law/Claims
Copyright/Trademark
Corporate/Business - Contracts
Corporate/Business - Formation/Alteration
Corporate/Business - General
Corporate/Business - Mergers/Acquisitions
Criminal
Disability/Social Security
Elder Law
Employment Law - Defense
Employment Law - Plaintiff
Entertainment/Sports
Environmental Law
ERISA
Estate/Probate/Trust/Wills (less than 1M)
Estate/Probate/Trust/Wills (1M – 5M)
Estate/Probate/Trust/Wills (greater than 5M)
Family Law (less than 1M)
Family Law (1M – 5M)
Family Law (greater than 5M)
Financial Institutions/Banks
Financial Planning
Foreclosure/Repossession
Government - Federal/State/Lobbying
Government - Local (no bond work)
Healthcare
Housing
Immigration/Naturalization
Insurance - Defense
Insurance - Plaintiff
Intellectual Property - Copyright
Intellectual Property - Patent/Trademark
International Law
Juvenile Proceedings
Labor Law - Management
Labor Law - Union
Landlord/Tenant
Limited Partnerships
Mass Tort - Plaintiff
Mediation/Arbitration
Medical Malpractice - Defense
Medical Malpractice - Plaintiff
Municipal (not bonds)
Natural Resources
Oil & Gas
Pension/Employee Benefits
Personal Injury/Negligence – Defense
Personal Injury/Negligence - Plaintiff
Public Utilities
Real Estate - Commercial
• Average $ transaction
• Maximum $ transaction
Real Estate - Residential
• Average $ transaction
• Maximum $ transaction
Securities Law - Federal SEC
Securities Law - Federal Exemptions
Securities Law - State SEC
Securities Law - Private Placements
Social Security
Syndication
Tax Shelters
Taxation - Individual
Taxation - Corporate
Water Law
Workers Compensation - Defense
Workers Compensation - Plaintiff
Other:
Other:

Carrier

Expiration Date

Premium $

Deductible $

Lim. of Lia. (per claim) $

Lim. of Lia. (aggregate) $

Retroactive Date

Defense Costs (check one)

Inside the Limits of Liabilty (defense costs erode coverage)Outside the Limits of Liability (defense costs do not erode coverage)50% Offset (defense costs erode 50% of the the coverage)

Deductible Type (check one)

FDD / Loss Only (deductible applies only when a loss occurs)Per Claim (deductible applies to each & every claim, regardless of the outcome)50% Offset (no more than 50% of the deductible can be applied to defense costs)Aggregate (deductible is only paid once per year, regardless of the number of claims)

Declarations Page & Endorsements OR Complete Policy

Upload a File

Please use the following initials as position keys: [O] Officer [S] Solo [P] Partner [E] Employed [PT] Part Time [IC] Independant Contractor [OC] Of Counsel

	Attorney Name	Bar Admin Date	Joined Firm	Ind. Retro Date	Position	Weekly Hours	CLE Hours (in past year)
1
2
3
4
5
6
7
8
9
10

If there are any IC or OC listed above, is this attorney a prior partner, officer or employee of the applicant firm?

YesNoN/A

If answered YES above, does this attorney carry his/her own individual professional liability insurance coverage?

YesNoN/A

Additional Information or Supplement Attorney Roster

Upload a File

Claims & Suits for Fees (if claims are present, an additional supplement &/or a loss/run report may need to be supplied.

	in the Present Year	in the Past 3 Years	in the Past 5 Years
Number of Claims
Number of Suits for Fees

Is the firm aware of any circumstances that may give rise to a claim? If so, please attach additional information below.

YesNo

Has any member of the firm been disciplined or denied the right to practice?

YesNo

Has the firm ever been non-renewed, canceled or declined coverage?

YesNo

Of which of the following does the firm's docket system consist?

How frequently is the docket system cross-checked?

DailyWeeklyMonthly

Is the docket system cross-checked by two separate individuals?

YesNo

Is the firm involved in any mass tort or class action work?

YesNo

Is there any one client who represents more than 25% of the firm's gross billing?

YesNo

Are all conflicts disclosed in writing?

YesNo

Of which letters does the firm use for ALL client communication?

What type of system is used to prevent a conflict of interest with clients?

Does any attorney serve as an outside director or officer and/or have any ownership interest in a client?

YesNo

Are there any predecessor firms of which the current firm has assumed 50% or more of the assets & liabilities?

YesNo

How many non-attorney staff are employed (secretarial & clerical)?

How many non-attorney staff are employed (paralegals/law clerks)?

Does the firm have a Legal Administrator?

YesNo

If answered YES above, is he/she a member of the ALA or hold a CLM certificate?

YesNoN/A

Has at least 50% of the firm's attorneys attended CLE in the past (12) months?

YesNo

Additional Supplements , Claim Information &/or Loss-Run Report

Upload a File

Thank you for taking the time to complete this questionnaire. Someone from our office will be in touch with you as soon as possible.

Lawyers' Professional Liability Questionnaire

Areas of Practice

Insurance History

Attorney Information

Additional Firm Information