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Lawyers Online Indication Form


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

General Information
Firm Name
Required
Year Established
Optional
Street
Required
City
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County
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State
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ZIP / Postal Code
Required
First Name
Required
Last Name
Required
Primary Phone Number
Required
Fax
Optional
E-Mail Address
Required
Application Upload
Optional
Current Policy Information
Current Coverage
Required

Policy Expiration Date
Optional
/ /
Exclusion Date Retroactive or "Prior Acts Date"
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/ /
Current Limits
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Current Deductible
Optional
Deductible Type
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Optional Coverages
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Current Insurance Carrier
Optional
Years of Continuous Coverage
Optional
Premium
Optional
Current Policy Declarations Page Upload
Optional
Attorney Information
Attorney 1
Name of Attorney 1
Required
Attorney 1 Date Began Private Practice
Optional
/ /
Attorney 1 Date Joined Firm
Optional
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Attorney 1 Status
Optional
Attorney 1 Hours Worked per Week
Optional
Attorney 1 Individual Retroactive Date
Optional
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Attorney 2
Name of Attorney 2
Optional
Attorney 2 Date Began Private Practice
Optional
/ /
Attorney 2 Date Joined Firm
Optional
/ /
Attorney 2 Status
Optional
Attorney 2 Hours Worked per Week
Optional
Attorney 2 Individual Retroactive Date
Optional
/ /
Attorney 3
Name of Attorney 3
Optional
Attorney 3 Date Began Private Practice
Optional
/ /
Attorney 3 Date Joined Firm
Optional
/ /
Attorney 3 Status
Optional
Attorney 3 Hours Worked per Week
Optional
Attorney 3 Individual Retroactive Date
Optional
/ /
Attorney 4
Name of Attorney 4
Optional
Attorney 4 Date Began Private Practice
Optional
/ /
Attorney 4 Date Joined Firm
Optional
/ /
Attorney 4 Status
Optional
Attorney 4 Individual Retroactive Date
Optional
/ /
Attorney 5
Name of Attorney 5
Optional
Attorney 5 Date Began Private Practice
Optional
/ /
Attorney 5 Date Joined Firm
Optional
/ /
Attorney 5 Status
Optional
Attorney 5 Hours Worked per Week
Optional
Attorney 5 Individual Retroactive Date
Optional
/ /
Areas Of Practice: Provide percentages of time devoted during the previous year in each area of practice (Must Total 100%)
General Practice Areas
Admiralty/Marine – Defense
Optional
Admiralty/Marine – Plaintiff
Optional
Anti-Trust/Trade Regulation
Optional
Arbitrator/Mediator
Optional
Banking/Financial Institutions
Optional
Bankruptcy
Optional
Civil Rights/Discrimination
Optional
Collections
Optional
Construction (Building Contracts)
Optional
Consumer Claims (not class action)
Optional
Criminal
Optional
Entertainment/Sports money mgmt
Optional
Entertainment/Sports No money mgmt
Optional
Environmental Law
Optional
ERISA/Pension/Employee Benefits
Optional
Govt. Contracts/Claims
Optional
Healthcare – Regulatory Compliance
Optional
Immigration/Naturalization
Optional
Intellectual Property
Optional
International Law
Optional
Labor/Employment – Management
Optional
Labor/Employment – Employee
Optional
Labor/Employment – Union
Optional
Lobbying
Optional
Local Govt./Municipal (not bonds)
Optional
Natural Resources/Oil & Gas
Optional
Other (please describe)
Optional
Other Desc.
Optional
Business Transactions/Corp. Law
Administrative
Optional
Formation of Entities
Optional
General Contract Negotiation
Optional
Mergers & Acquisitions
Optional
Secured Transactions
Optional
Family Law
Adoption
Optional
Divorce – Marital Assets < 1M
Optional
Divorce – Marital Assets > 1M
Optional
Elder Law
Optional
Guardianship/Juvenile
Optional
Social Security
Optional
Litigation
Class Action/Mass Tort – Defense
Optional
Class Action/Mass Tort – Plaintiff
Optional
General Commercial – Defense
Optional
General Commercial – Plaintiff
Optional
Insurance Defense
Optional
Personal Inj./Prop Damage – Defense
Optional
Personal Inj./Prop Damage – Plaintiff
Optional
Personal Inj/Med Mal -Plaintiff
Optional
Work Comp – Defense
Optional
Work Comp – Plaintiff
Optional
Real Estate
Abstracting/Title – Commercial
Optional
Abstracting/Title – Residential
Optional
Conveyance – Commercial
Optional
Conveyance – Residential
Optional
Foreclosures & Loan Workouts
Optional
Landlord/Tenant
Optional
Syndications/Ltd. Partnerships
Optional
Zoning & Planning
Optional
Taxation
Business
Optional
Individual
Optional
Tax Litigation
Optional
Opinions
Optional
Wills, Estate, Trust, Probate
For assets < 1M
Optional
For assets > 1M
Optional
Does the firm have a docket system with two independent date controls?
Optional

Do you have a conflict of interest avoidance system?
Optional

Do you use engagement/disengagement letters?
Optional

How many times has your firm sued a client for fees in the last 2 years?
Optional
Total number of employees including attorneys
Optional
Firm Gross Revenue
Optional
Any Professional Liability claims or incidents reported against any of the attorneys’ listed, prior partners or associates in the last 5 years?
Optional

Is the firm aware of any circumstance(s) or act(s) which may give rise to a claim?
Optional

Have any of the firm's attorneys been the subject of any disciplinary action, for any reason other than non-payment of dues, within the last 5 years?
Optional

Claim Description
Optional
NOTE: This Form is for Estimate Purposes Only. Coverage May Be Bound Only Upon Submission and Acceptance of a Completed Application
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

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