attorneyPL

APPLICANT INFORMATION:

Applicant/Firm Name

DBA

Address

Address (cont)

City

State

ZIP

email Address

Phone Number

Website URL

Effective Date Requested

Number of Attorneys

Attorney Names, State Bar #s, Hire Dates

Are any attorneys employed part-time (750 hour per year or less)?

Yes
No

If yes, how many are part time attorneys?

Does your firm specialize more than 50% in any area of practice?

Yes
No

If Yes, what is your primary are of practice?

Does your firm practice in any of the following areas of practice (AOP)?

Securities
Entertainment
Intellectual Property
Real Estate Syndication
Formation of General Limited Partnership or Limited Partnership
Formation of Real Estate Investment Trust with respect to Real Property

How many suits and fee arbitrations for collection of fees and/or recovery of costs have been commenced by the Applicant during the past five (5) years?

In the past five years has any professional liability claim or suit been made against the applicant or predecessor firms?

Yes
No

COVERAGE REQUEST:

Combined Limit Requested: (each occurrence/aggregate)

Deductible Requested

POLICY HISTORY (if currently insured):

Retroactive Date of Current Coverage

Carrier

Policy Number

Effective From

Effective To

Premium