Professional Liability Quote

INSURANCE CONSULTING SERVICES, LLC
The Lawyers Malpractice Insurance Specialists

PROFESSIONAL LIABILITY
QUICK QUOTE FORM

Firm Name:

Contact Name:

Street Address:

City/State/Zip:

Telephone:

Fax:

E-Mail:

Date firm was established:

Current Insurance Information– Include your current policy’s Declarations Page.

Carrier:

Policy Expiration Date:

Limits of Liability:

Prior Acts Date:

Deductible:

Current Premium:

Areas of Practice, Total 100% - based on income from each area, please complete subcategories as indicated.

%	Administrative
%	Arbitration/Mediation
%	Banking/Fin. Instit.
%	Bankruptcy
%	Collections
%	Corporate Law
	% Formation/Alt.
	% M/A
	% General Corp.
%	Criminal
%	Environmental
%	Family Law:
	% Non-Divorce
	% Divorce
%	Immigration
%	Insurance Defense
%	Intellectual Property:
	% Copyright
	% Patent
	% Trademark
%	Labor/Employment:
	% Management
	% Employee
	% Labor/Union
%	Oil & Gas
%	PI/BI Plaintiff:
	% Med Mal
	% Class Action
	% Other (Auto,Slip/Fall etc)
%	PI/BI Defense
%	Wills, Trusts & Estates
	% Estates Under $500 K
	% Estates Over $500K (please list separately)
%	Real Estate:
	% Commercial
	% Residential
	% Title Work
%	Securities Law:
	% Registrations
	% Private Placement
	% Opinions
%	Tax
	% Opinion Letters
	% Preparation
%	Water Law
%	Workers Comp:
	% Defense
	% Plaintiff
%	Other (please list separately)

Other Areas of Practice

(Please explain)

Firm Management

1. Does any attorney have more than 10% interest in a company that is also a client?

Yes No

2. Does any attorney act as director, officer or employee of a client?

Yes No (provide details)

3. Has any attorney had a claim, been reprimanded or suspended in the past 5 years?

Yes No (provide details)

4. Does your firm use: (check each used)

Engagement Letters Termination Letters Fee Agreements

5. Conflict of interest system:

Computer Single Index Multi Index Conflicts Software

6. Docket control system:

Computer Dual Calendar Tickler Day-timer Other

7. Is your Docket system checked:

Daily Weekly Monthly

8. In the past 2 years how many clients have been sued for failure to pay fees?

9. Please indicate number of: Paralegals Secretaries Receptionists

10. Please indicate total number of employees.

Additional details of above

List of Attorneys

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