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Please select your preferred method of contact:
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I would like a representative to call me with a quote. I would like a quote by return email. I would like a quote by fax.
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Please provide us with pertinent contact information for your firm:
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| *Your Name |
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| *Firm Name |
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| *State |
*Zip |
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(Please note that our services are available only for the states listed.) |
| *Email |
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| Phone |
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List the first date of employment for each attorney employed in your firm:
Include yourself and any "of counsel" and "independent contractor" attorneys
you want insured in your policy.
Start Date (mm/yy, mm/yy, mm/yy, etc.)
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Do you practice Part time?
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Yes No
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| If part-time, please complete the following: |
Average # of hours per week:
per week |
Length of time you have been working these hours:
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Estimate the percentage of hours per year you work in each area
of practice.
Must total 100% |
| Percentage |
Area of Practice |
| % |
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| % |
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| % |
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| % |
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| % |
Other (if more than 5%, describe below) |
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Does your firm currently have professional liability insurance?
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Yes No
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| Current policy expires on (approximate date if unknown): |
| Month Year |
The estimated date you first became insured and have been insured
continuously ever since: |
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Month Year |
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How did you hear about us?
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Any additional Comments or Questions:
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