Lawyer’s Professional Liability Quote Contact Name* First Last Firm Name*Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Office PhoneCell PhoneHow may we contact you?EmailOffice phoneCell phoneDate Firm EstablishedMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Number of AttorneysNumber of Support StaffNumber of "Of Counsel"Number of hours per week for each OCATTORNEY EXPERIENCEPlease provide the number of attorneys for each number of years with the firm.5+ Years4 Years3 Years2 Years1 Year6 months or lessEstimated Gross IncomeIs this a full-time, private practice of law?YesNoDo you maintain a Docket Control System with at least two independent date controls?YesNoIs a Conflict of Interest System maintained?YesNoAre engagement and non-engagement letters used on a regular basis?YesNoCURRENT INSURANCECarrierLimits & DeductiblesRetroactive/Prior Acts DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Policy TermDate of first continuous claims-made coverageMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920CLAIM HISTORYAre you aware of any claims against you or your firm or incidents that may result in a claim in the past 5 years?YesNoHas any member of the firm been refused admission to practice, disbarred, suspended, reprimanded, sanctioned, or held in contempt by the court administrative agency or regulatory body?YesNoAREA OF PRACTICE PERCENTAGESUsing the drop-down menus, select your Primary, Secondary, or Other areas of practice and include an approximate percentage of each area to reach 100%.Primary Area of PracticeAdministrationAdmiralty/MaritimeAntitrust/Trade RegulationArbitration/MediationBanking/FinanceBankruptcyBI/PI DefenseBI/PI Plaintiff*Civil Rights/DiscriminationCollection/RepossessionCommunication/FCCCopyright/TrademarkCorporate-FormationCorporate-GeneralCriminalDomestic RelationsEmployee BenefitsEntertainment/SportsEnvironmentalEstates/Probate/Wills/TrustForeign/InternationalHealthcareInsuranceInvestments/Money ManagementLabor Law/UnionMergers & AcquisitionsMunicipalOil/Gas/MineralsPatentPublic UtilitiesReal Estate/CommercialReal Estate/ResidentialSchool LawSecuritiesSocial Security/Elder LawTax/CorporateTax/IndividualWater RightsWork Comp/DefenseWork Comp/PlaintiffOtherPercentagee.g., 25%Secondary Area of PracticeAdministrationAdmiralty/MaritimeAntitrust/Trade RegulationArbitration/MediationBanking/FinanceBankruptcyBI/PI DefenseBI/PI Plaintiff*Civil Rights/DiscriminationCollection/RepossessionCommunication/FCCCopyright/TrademarkCorporate-FormationCorporate-GeneralCriminalDomestic RelationsEmployee BenefitsEntertainment/SportsEnvironmentalEstates/Probate/Wills/TrustForeign/InternationalHealthcareInsuranceInvestments/Money ManagementLabor Law/UnionMergers & AcquisitionsMunicipalOil/Gas/MineralsPatentPublic UtilitiesReal Estate/CommercialReal Estate/ResidentialSchool LawSecuritiesSocial Security/Elder LawTax/CorporateTax/IndividualWater RightsWork Comp/DefenseWork Comp/PlaintiffOtherPercentagee.g., 25%Other Area of PracticeAdministrationAdmiralty/MaritimeAntitrust/Trade RegulationArbitration/MediationBanking/FinanceBankruptcyBI/PI DefenseBI/PI Plaintiff*Civil Rights/DiscriminationCollection/RepossessionCommunication/FCCCopyright/TrademarkCorporate-FormationCorporate-GeneralCriminalDomestic RelationsEmployee BenefitsEntertainment/SportsEnvironmentalEstates/Probate/Wills/TrustForeign/InternationalHealthcareInsuranceInvestments/Money ManagementLabor Law/UnionMergers & AcquisitionsMunicipalOil/Gas/MineralsPatentPublic UtilitiesReal Estate/CommercialReal Estate/ResidentialSchool LawSecuritiesSocial Security/Elder LawTax/CorporateTax/IndividualWater RightsWork Comp/DefenseWork Comp/PlaintiffOtherPercentagee.g., 25%*If selected *"BI/PI Plaintiff", is any of this work Class Action/Mass Tort?YesNoAdditional Comments