Form

Agent Information

First Name

Last Name

Phone Number

Insured Information

First Name*

Last Name*

Street Address*

City*

State/Region*

Postal Code*

Email*

Phone Number*

Attorney Information

ATTORNEY 1

Attorney 1 First Name

Attorney 1 Last Name

Attorney 1 Designation

Attorney 1 Years in Practice

Attorney 1 Date of Hire

Attorney 1 Weekly Hours Worked

ATTORNEY 2

Attorney 2 First Name

Attorney 2 Last Name

Attorney 2 Designation

Attorney 2 Years in Practice

Attorney 2 Date of Hire

Attorney 2 Weekly Hours Worked

ATTORNEY 3

Attorney 3 First Name

Attorney 3 Last Name

Attorney 3 Designation

Attorney 3 Years in Practice

Attorney 3 Date of Hire

Attorney 3 Weekly Hours Worked

ATTORNEY 4

Attorney 4 First Name

Attorney 4 Last Name

Attorney 4 Designation

Attorney 4 Years in Practice

Attorney 4 Date of Hire

Attorney 4 Weekly Hours Worked

ATTORNEY 5

Attorney 5 First Name

Attorney 5 Last Name

Attorney 5 Designation

Attorney 5 Years in Practice

Attorney 5 Date of Hire

Attorney 5 Weekly Hours Worked

Have more than 5 attorneys? Download this form, fill out, and upload below.

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Practice Distributions For Each Practice Area. (The total of all areas of practice should equal 100%)

Admirality / Maritime

Antitrust

Aviation

Bankruptcy

Business Litigation

Civil Rights

Collections

Commercial Law

Communications / Media

Construction Law

Consumer Claims

Corporate Law

Criminal Law

Disability / Social Security

Elder Law

Employment

Entertainment

Environmental Law

Estates / Trusts / Probate

Family Law

Financial Institutions

Government

Healthcare

Immigration

Insurance

Intellectual Property

International Law

Investment Counseling / Money Management

Labor - Union Related Work

Medical Malpractice

Oil / Gas

Personal Injury

Public Utilities

Real Estate

Secured Transaction (UCC - Commercial Paper)

Securities Law (Except Corporate Formation)

Taxation

Workers' Compensation

Does the firm engage in class action/mass tort?*

INSURANCE

Does your firm currently have insurance?*

CLAIMS

Has your firm reported any claims in the past 5 years?*

Suspension*

DISCLAIMER

No coverage is bound or implied by submitting information via this online form. Premium estimates provided form information on this form are only anticipated pricing and non-binding indications. Actual quotes are subject to completion and acceptance of a new business application with suppliments (if applicable) and underwriting approval. Estimates may decrease or increase based on information provided to us in your application.

Not all policies or coverages are available in every state.

Any information provided by this online form will be used to assist in obtaining appropriate insurance estimates. We will not distribute information to other than for underwriting purposes.

Additional Comments or Questions