FirmPro Premium Estimate form

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Florida Legal Malpractice Insurance Request for Premium Estimate
Name of Law Firm*
Contact Name*
First Last
Phone*
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Website
Please indicate the coverage desired below
Limit of Liability
Deductible
Firm’s Areas of Practice during the previous year (whole numbers only please) – must total 100%
Admiralty/Marine
Please enter a number from 0 to 100.
Antitrust/Trde Regulation
Please enter a number from 0 to 100.
Bankruptcy
Please enter a number from 0 to 100.
Bond
Please enter a number from 0 to 100.
Collection/repossession
Please enter a number from 0 to 100.
Commercial Trasnsactions: Finance
Please enter a number from 0 to 100.
Commercial Trasnsactions: Secured
Please enter a number from 0 to 100.
Communications
Please enter a number from 0 to 100.
Corporate: Formation/Alteration
Please enter a number from 0 to 100.
Corporate: Margers/Acquisitions
Please enter a number from 0 to 100.
Corporate: Other(Explain)
Please enter a number from 0 to 100.
Criminal
Please enter a number from 0 to 100.
Energy/Natural Resources
Please enter a number from 0 to 100.
Entertainment/Sports
Please enter a number from 0 to 100.
ERISA
Please enter a number from 0 to 100.
Estate/Trust/probate
Please enter a number from 0 to 100.
Family Law/Domestic Relations
Please enter a number from 0 to 100.
Financial Institutions/Banking
Please enter a number from 0 to 100.
Government/Municipal (not bonds)
Please enter a number from 0 to 100.
Immigration/Naturalization
Please enter a number from 0 to 100.
Intellectual Property - Patent
Please enter a number from 0 to 100.
Intellectual Property - Trademark
Please enter a number from 0 to 100.
Intellectual Property - Copyright
Please enter a number from 0 to 100.
Labor: Union-Management Relations
Please enter a number from 0 to 100.
Labor: Employment Law
Please enter a number from 0 to 100.
Litigation: Arbitration/Mediation
Please enter a number from 0 to 100.
Litigation: Commercial
Please enter a number from 0 to 100.
Litigation: General Civil
Please enter a number from 0 to 100.
Litigation: Insurance Defense
Please enter a number from 0 to 100.
Litigation: Plaintiff
Please enter a number from 0 to 100.
Personal Injury: Plaintiff
Please enter a number from 0 to 100.
Personal Injury: Defense
Please enter a number from 0 to 100.
Pro-bono: Criminal
Please enter a number from 0 to 100.
Pro-bono: Other
Please enter a number from 0 to 100.
Real Estate: Commercial
Please enter a number from 0 to 100.
Real Estate: Residential
Please enter a number from 0 to 100.
Real Estate: Land Use/Zoning
Please enter a number from 0 to 100.
Real Estate: Title Examinations
Please enter a number from 0 to 100.
Securities
Please enter a number from 0 to 100.
Taxation: Corporations
Please enter a number from 0 to 100.
Taxations: Individuals
Please enter a number from 0 to 100.
Workers Compensations: Plaintiff
Please enter a number from 0 to 100.
Workers Compensations: Defendant
Please enter a number from 0 to 100.
Others (Attach description)
Please enter a number from 0 to 100.
Total
must total 100%
Number of non-lawyer staff
Estimated Annual Revenue

Attorney Name

*Designation Code

Average #Hours/Week

States Licensed

#Years in practice

#Years with firm

Prior Acts Date

*Designations: A=Associate CC=Co-Counsel D=Director E=Employee IC=Independent Contractor OC=Of Counsel SP=Sole Practitioner P=Partner RP=Retired Partner
Insurance History for past five years: (if none – check here: None)

Policy Period

Insurer

Limits of Liability

Deductible

Premium

# of lawyers

Does your firm’s current professional liability policy contain a limitation on prior acts coverage? (prior acts exclusion, retroactive date, etc).
- Yes
- No
If yes, please provide date
Does the firm or any attorney have any clients in the Entertainment Industry?
- Yes
- No
Has any attorney provided legal services related to securities transactions (anywhere) in past 5 years?
- Yes
- No
Do the attorneys of this firm have any equity interest in its client(s)
- Yes
- No
Does the firm have any one client that generates more than 25% of the firm’s billings
- Yes
- No
Does anyone in the firm serve as a director, officer, employee or manager of any of a client?
- Yes
- No
Does the firm have a formal conflict of interest avoidance system?
- Yes
- No
If yes, is the firm’s conflict of interest system computerized?
- Yes
- No
Does the firm have at least two independently maintained date/deadline control systems?
- Yes
- No
If yes, does the firm have a formal computerized docket control program?
- Yes
- No
Does the firm regularly use written engagement agreements?
- Yes
- No
Does the firm regularly use written declination and termination letters?
- Yes
- No
If you are a solo practitioner, do you have a back up attorney?
- Yes
- No
Do you have any publically traded clients?
- Yes
- No
Has the firm been involved in any Mass Tort / Class Action cases in the past five years?
- Yes
- No
Claims / Incidents / Disciplinary Information / Fee Suits
Has the firm initiated lawsuits or arbitration procedures during the past two years to collect unpaid fees? (If yes, please also indicate how many)
- Yes
- No
Has any professional liability claim(s) or suit(s) been made against the firm or the attorneys in the past 5 years? (If yes, please complete a claim supplement for each)
- Yes
- No
Are you or the attorneys aware of any actual or alleged circumstance which may give rise to a claim? (If yes, please complete a claim supplement for each)
- Yes
- No
Have you or any of the attorneys been subject to any disciplinary inquiry, complaint, or proceedings? (If yes, please attach full details)
- Yes
- No
Has your or any of the attorneys been refused admission to practice, disbarred, suspended, formally reprimanded, or sanctioned in any way? (If yes, please attach full details)
- Yes
- No
This form is being submitted for a non‐binding premium indication only. By providing your phone number, fax number and email address, you are providing us with permission to respond to your request for legal malpractice insurance premium indications by phone, fax and/or email. This information is confidential and never provided to or sold to any other party.
Signed
Date

Florida Legal Malpractice Insurance Request for Premium Estimate

Please indicate the coverage desired below

Firm’s Areas of Practice during the previous year (whole numbers only please) – must total 100%

C&R INSURANCE SERVICES, LLC.

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