Lawyers Professional Liability Application Order Number Name of Firm Street Address Street Address Line 2 City State Postal / Zip Code County E-mail Phone Contact Name Additional Limit options to be included in your quote $100,000/$300,000 $200,000/$600,000 $250,000/$750,000 $500,000/$1,000,000 $1,000,000/$1,000,000 $1,000,000/$2,000,000 $1,000,000/$3,000,000 $2,000,000/$2,000,000 $2,000,000/$4,000,000 $3,000,000/$3,000,000 $4,000,000/$4,000,000 $5,000,000/$5,000,000 Please state the name, status code, firm hire date, bar admission date, states licensed, annual hours worked, hours of CLE or ethics/loss prevention over the past 12 months, and the retroactive date if different from firm retroactive date for ALL members of your firm. Please indicate your area of practice Administrative Admiralty/Marine Antitrust/Trade Regulation Bankruptcy Collection/Repossession Communications/FCC Construction/Building Contracts Commercial/Corporate Criminal Elder/Senior Law Employment/Civil Rights Energy/Oil/Gas/Natural Resources/Mineral Rights Entertainment/Sports/Celebrity/Public Figures ERISA/Employee Benefits/Pension Estate/Trust/Probate/Wills Environmental Family Law Financial Institutions/Banking Government/Municipal Healthcare Immigration/Naturalization Intellectual Property Investment Counseling/Money Mgmt International Law Labor Relations/Employment Law Labor Law - Management Labor Law - Union/Employee Litigation - General Real Estate Securities/Bonds Social Security Law Taxation - Corporate and Individual Water Rights Law Workers Compensation - Defense Workers Compensation - Plaintiff Have you had any claims in the last 5 years? Are you aware of any potential claims? Yes No
