Please provide me with your most competitive NO OBLIGATION premium estimate for professional liability coverage
Firm
Contact
Address
City
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State
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Phone
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Staff List (Designations: O=Owner, P=Partner, A=Associate, IC=Independent Contractor, OC=Of Counsel, PA=Patent Agent) Name, Hire Date, Designation
Are engagement letters or retainer agreements, that establish the scope of your firm's representation, required to be sent to all new clients? yesno
Have you ever sued a client (past or present) for uncollected fees? yesno
Has any member of your firm handled class action or mass tort litigation in the past 5 years? yesno
Has any member of your firm been disbarred or been the subject of a disciplinary proceeding? yesno
Area of Practice - What percentage of gross billings are earned from the following (Total Must Equal 100%):
*Describe other services below:
Insurance History
Renewal Date
Insurer
Limit
Deductible
Retroactive Date (if applicable)
Current annual premium
Claims History (if applicable):
Claim 1 Date Claim or Incident Reported: Amount Paid (Including Expenses): Open/Closed:
Claim 2
Date Claim or Incident Reported: Amount Paid (Including Expenses): Open/Closed:
Claim 3
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