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Firm Name*:

Street Address*:

City/Town*:

County:
State*:
Zip*:

Phone:
Email Address*:

Date of Establishment:

Contact Name*:

Insurance History:

Current Carrier:
Current Expiration Date:

Retroactive Date:

Current Limits:
Current Deductible:
Current Premium:
# Expiring Attorneys:

Claim Expenses Outside Limit:
YesNo

Per Claim Deductible First Dollar Defense Deductible Aggregate Deductible

Attorney Information*:

Number of attorneys in the firm for 6+ years:

Number of attorneys in the firm for 5 years:

Number of attorneys in the firm for 4 years:

Number of attorneys in the firm for 3 years:

Number of attorneys in the firm for 2 years:

Number of attorneys in the firm for 1 year:

Number of attorneys in the firm for < 1 year:

TOTAL # OF ATTORNEYS IN THE FIRM:

Area of practice information*:

%
Administrative Law
%
Financial Institutions/Banking*

%
Admiralty Law
%
Government Contracts and Claims

%
Adoption Law
%
Guardianship/Juvenile

%
Antitrust/Trade Regulation
%
Immigration and Naturalization

%
Arbitration/Mediation
%
Insurance Defense

%
Bankruptcy
%
I. P. Copyrights & Trademarks*

%
Business Transactions & Contracts
%
I.P. Patents*

%
Civil Rights and Discrimination
%
International Law

%
Class Actions/Mass Tort*
%
Local Government (not bonds)

%
Collection/Repossession – Commercial
%
Oil & Gas

%
Collection/Repossession – Consumer
%
Personal Injury – Defense

%
Commercial Litigation – Defense
%
Personal Injury – Plaintiff

%
Commercial Litigation – Plaintiff
%
Real Estate – Commercial

%
Construction/Building Contracts
%
Real Estate – Foreclosure

%
Consumer Claims
%
Real Estate – Land Use & Zoning

%
Corporate & Business Formation
%
Real Estate – Residential

%
Corporate Mergers and Acquisitions
%
Real Estate –Title

%
Criminal
%
Securities or Bonds*

%
Divorce – w/ Assets < $1M
%
Social Security

%
Divorce – w/ Assets $1M - $5M
%
Taxation

%
Divorce – w/ Assets > $5M
%
Wills, Trusts & Estates < $1M

Value of largest divorce case in 2 years:
%
Wills, Trusts & Estates $1M - $5M

%
Eminent Domain
%
Wills, Trusts & Estates > $5M

%
Employment Law – Employee /Union
Value of largest WTE case in 2 years:

%
Employment Law – Employer /Management
%
Workers Compensation – Defense

%
Entertainment
%
Workers Compensation – Plaintiff

%
Environmental Law
%
Other (Describe):

%
ERISA/Employee Benefits
%
BOTH COLUMNS MUST TOTAL 100%

Fee Suit and Claim History Information:

How many suits for fees have you filed against your clients in the last two (2) years?

Any professional liability claims or incidents reported against any of the attorneys listed, prior partners or associates in the last 5 years? * If yes, please provide loss runs.*
YesNo
Have any of the firm’s attorneys been the subject of any disciplinary action, for any reason other than non-payment of dues, within the last ten (10) years?*
YesNo

* = We may need additional information to provide an estimate.

The information collected herein will be used for our underwriting purposes and will be shared with an LPP Preferred Agent appointed to write business with us in your domicile state.