Insuring Lawyers| Attorneys Advocate program, professional liability insurance law, and contemptible public liability insurance

Producer Name: C & R Insurance Services

Producer Number: 8003

National Liability & Fire Insurance Company

Premium Indication Request

Download Indication Form Here or Fill Out the Following to Submit Online

FIRM INFORMATION

FIRM NAME

CONTACT NAME

SUITE

STREET ADDRESS

CITY

STATE

ZIP

COUNTY

BUSINESS PHONE (XXX-XXX-XXXX)
--

BUSINESS FAX (XXX-XXX-XXXX)
--

NUMBER OF ATTORNEYS:

EMAIL ADDRESS

WEB ADDRESS(ES)

WHAT DATE WAS THE FIRM ESTABLISHED?
// (MM/DD/YYYY)

CURRENT RETROACTIVE DATE
// (MM/DD/YYYY)

LIMITS REQUESTED?
$

DEDUCTIBLE REQUESTED
$

EXPIRATION DATE OF THE FIRM'S CURRENT LAWYERS PROFESSIONAL LIABILITY POLICY
// (MM/DD/YYYY)

CURRENT INSURANCE:

INSURANCE COMPANY	LIMITS (PER CLAIM/AGG)	DEDUCTIBLE (PER CLAIM/AGG)	PREMIUM
	$	$	$

INDICATION QUESTIONS

A. HAVE THERE BEEN ANY GAPS IN CONTINUOUS CLAIMS-MADE COVERAGE FOR THE LAST 8 YEARS?

Yes No

FROM // (MM/DD/YYYY) TO // (MM/DD/YYYY)
REASON:

DOES THE FIRM’S CURRENT LEGAL PROFESSIONAL LIABILITY POLICY HAVE ANY CUSTOMIZED ENDORSEMENTS SPECIFIC TO THE FIRM OR LIMITATION OF PRIOR ACTS COVERAGE INCLUDING PRIOR ACTS EXCLUSIONS?

Yes No

IF YES, PLEASE ATTACH

C. DOES THE FIRM SHARE ANY OF THE FOLLOWING WITH OTHER ATTORNEYS OR FIRMS?
OFFICE SPACE EXPENSES SUPPORT STAFF LETTERHEAD CASES FEES NONE

D. MOST RECENT ANNUAL GROSS REVENUES: $

MAXIMUM SINGLE CASE VALUE IN PAST 24 MONTHS: $

E. ATTORNEYS LEAVING/JOINING THE FIRM IN THE LAST 12 MONTHS

LEAVING JOINING

F. HAS THE FIRM OR ANY ATTORNEY FOR WHOM COVERAGE IS SOUGHT EVER BEEN INVOLVED, DIRECTLY OR INDIRECTLY, IN A CLAIM, POTENTIAL CLAIM, OR SUIT ARISING OUT OF THE RENDERING OR FAILING TO RENDER LEGAL SERVICES?

Yes No
IF YES, HOW MANY?

G. DETAILS OF LARGEST CLAIM
DATE // (MM/DD/YYYY) CARRIER

VALUE AOP

H. IS THE FIRM OR ANY ATTORNEY FOR WHOM COVERAGE IS SOUGHT AWARE OF ANY ACT, ERROR, OMISSION OR INCIDENT REASONABLY BE EXPECTED TO RESULT IN A CLAIM OR SUIT BEING MADE AGAINST THEM?

Yes No
IF YES, HOW MANY?

I. DETAILS OF LARGEST CLAIM
DATE // (MM/DD/YYYY) CARRIER

VALUE AOP

J. HAS THE FIRM OR ANY ATTORNEY FOR WHOM COVERAGE IS SOUGHT EVER BEEN DISBARRED, REFUSED ADMISSION TO PRACTICE LAW, SUSPENDED, REPRIMANDED, SANCTIONED, FINED, PLACED ON PROBATION, HELD IN CONTEMPT OR THE SUBJECT OF DISCIPLINARY ACTION OF ANY KIND BY A COURT, ADMINISTRATIVE OR REGULATORY BODY?

Yes No

K. WHAT PERCENTAGE OF THE FIRM’S BILLINGS ARE OVER 90 DAYS OVERDUE?

L. HOW MANY SUITS HAS THE FIRM FILED AGAINST ITS OWN CLIENTS FOR THE COLLECTION OF FEES IN THE PAST 5 YEARS?

M. HAS THE FIRM OR ANY OF ITS PAST OR PRESENT ATTORNEYS SERVED AS AN OFFICER, DIRECTOR OR EMPLOYEE OF A FOR-PROFIT OR NON-PROFIT ENTERPRISE OTHER THAN THE FIRM, OR HAD ANY KIND OF DEBT, EQUITY OR OWNERSHIP INTEREST IN A CLIENT OF THE FIRM, OR ENGAGED IN ANY BUSINESS VENTURE WITH A CLIENT OF THE FIRM?

Yes No

N. CHECK ALL THAT APPLY
CLIENT SCREENING
ENGAGEMENT LETTERS FEE AGREEMENTS NON-ENGAGEMENT LETTERS DISENGAGEMENT LETTERS

CONFLICT AVOIDANCE
INDEX ORAL/MEMORY COMPUTER NO SYSTEM WRITTEN PROCEDURE

CALENDARING/DOCKET CONTROL
AT LEAST 2 INDEPENDENT SYSTEMS A COMPUTERIZED SYSTEM NONE OF THE ABOVE
A DESIGNATED DOCKET CONTROL OR CALENDARING PERSON RESPONSIBLE FOR THE FIRM'S DEADLINES

O. DOES ANY OF THE FIRM'S WORK INVOLVE REPRESENTATION OF PLAINTIFFS IN CLASS ACTION OR MASS TORT
LITIGATION?

Yes No

P. USING THE CHART BELOW, PLEASE IDENTIFY THE FIRM'S AREAS OF PRACTICE BASED ON THE FIRM'S GROSS BILLINGS IN THE MOST RECENT COMPLETE FISCAL YEAR.

AREA OF PRACTICE	LAST YEAR	THIS YEAR	CURRENT BREAKDOWN WITHIN PARTICULAR AREA OF LAW (SHOULD TOTAL 100%)
ADMIRALTY/MARITIME	%	%	% PLAINTIFF	% DEFENSE		% OTHER
ANTITRUST/TRADE REGULATION	%	%	% PLAINTIFF	% DEFENSE		% OTHER
APPELLATE	%	%
BANKRUPTCY	%	%	% CREDITOR	% DEBTOR		% COURT APPOINTED TRUSTEE
BUSINESS & COMMERCIAL LITIGATION	%	%	% PLAINTIFF		% DEFENSE
BUSINESS FORMATION & ALTERATION	%	%	% FORMATION DISSOLUTION	% MERGERS & ACQUISITIONS		% OTHER
BUSINESS TRANSACTIONS/ COMMERCIAL LAW	%	%	% PUBLIC CORPORATIONS	% PRIVATE CORPORATIONS/INDIVIDUALS		% OTHER
CIVIL RIGHTS & DISCRIMINATION	%	%	% PLAINTIFF	% DEFENSE		% OTHER
COLLECTIONS	%	%	% CREDITOR	% DEBTOR		% OTHER
CONSTRUCTION LAW/ BUILDING CONTRACTS	%	%	% PLAINTIFF	%DEFENSE		% TRANSACTIONAL
CONSUMER CLAIMS (NOT CLASS ACTION)	%	%
CRIMINAL LAW	%	%
ELDER LAW (NOT TAX OR ETP)	%	%
* ENTERTAINMENT LAW	%	%	% INCLUDING MONEY MANAGEMENT		% EXCLUDING MONEY MANAGEMENT
ENVIRONMENTAL LAW	%	%	% PLAINTIFF	% DEFENSE		% OTHER
ESTATES/TRUST/PROBATE	%	%	% ESTATE PLANNING	% TRUST ADMINISTRATION		% OTHER
FAMILY LAW	%	%	% DIVORCE	% ADOPTION		% OTHER
FEDERAL, STATE GOVERNMENT/LOBBYING	%	%	% GENERAL OR FINANCIAL ADVICE	% DEFENSE		% OTHER
* FINANCIAL INSTITUTIONS	%	%
IMMIGRATION & NATURALIZATION	%	%
* INTELLECTUAL PROPERTY	%	%	% PATENT	%TRADEMARK COPYRIGHT		% LITIGATION
INTERNATIONAL LAW	%	%
LABOR/EMPLOYMENT	%	%	% MANAGEMENT	% UNION/LABOR		% OTHER
NATURAL RESOURCES/OIL & GAS	%	%	% PLAINTIFF	% DEFENSE		% OTHER
* PERSONAL INJURY/ PROPERTY DAMAGE	%	%	* CLASS ACTION/ % MASS TORT PLAINTIFF		* CLASS ACTION/ % MASS TORT DEFENSE
			* MEDICAL % MALPRACTICE PLAINTIFF		* MEDICAL % MALPRACTICE DEFENSE
			*% OTHER PI/BI PLAINTIFF**		*% OTHER PI/BI DEFENSE**
* REAL ESTATE	%	%	% COMMERCIAL		% RESIDENTIAL
* SECURITIES/ CORPORATE BONDS	%	%	% CORPORATE BONDS		% OTHER
TAXATION/TAX OPINIONS/TAX SHELTERS	%	%	% TAX SHELTERS	% CORPORATE		% OTHER
WORKERS' COMPENSATION	%	%	% EMPLOYER		% EMPLOYEE
OTHER	%	%	PLEASE DESCRIBE:
	%	%

THIS PREMIUM INDICATION REQUEST DOES NOT CONSTITUTE AN APPLICATION FOR INSURANCE COVERAGE AND INDICATED PREMIUMS OR TERMS RESULTING FROM THIS REQUEST ARE NOT OFFERS OF COVERAGE. IF PROVIDED, ANY INDICATED PREMIUM OR TERMS MAY WIDELY VARY FROM ANY SUBSEQUENT INDICATED OR QUOTED PREMIUM OR TERMS.