Couch Braunsdorf

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FIRM'S INFORMATION

Name of Firm *

Contact Name*

Contact's Title

Address*

County

City*

State*

Zip Code*

Email*

Phone*

Fax*

Website

Date Firm Established*

ARE YOU A SOLE PRACTITIONER?

Are you a sole practitioner?*

CURRENT (OR DESIRED) COVERAGE

Current Carrier*

Expiration Date of Existing Policy*

Retroactive Date*

Number of Attorneys in Firm*

Limit of Liability*

Deductible*

Premium*

Has this firm (regardless of name changes) been insured for at least 5 years?*

Date Continuously Insured From*

LIST OF ATTORNEYS (INCLUDE SELF)

Full Name *

Designation Code *

Date Hired *

Hours Worked / Week *

Years In Private Practice *

Add Attorney

Attorneys Added

Attorney Name	Actions

AREAS OF PRACTICE

In order to provide you with a quote for your LPL renewal we need you to tell us each area of practice your firm participates in and the percentage of time the area is practiced

To add areas of practice, Please select the appropriate area of practice from the drop down box, then enter the percentage of time (from 1% to 100%)---then click add area of practice

Area of Practice *

Percent of Practice *

Add Area of Practice

Areas of Practice Added

Area of Practice	Percent of Practice	Actions

CLAIMS, POTENTIAL CLAIMS AND DISCIPLINARY ACTIONS

Has any professional liability claim or suit been made in the past five (5) years against the firm or its predecessor firm(s) or any current or former member of the firm or its predecessor firm(s)?*

After inquiry, does any firm member know of any circumstance, situation, act, error or omission that could result in a professional liability claim or suit against the firm or its predecessor firm(s) or any current or former member of the firm or its predecessor firm(s)?*

Has member of the firm ever been refused admission to practice, disbarred, suspended, reprimanded, sanctioned or have any disciplinary complaints or ongoing disciplinary investigations?*

In the past five years, has a professional liability insurer declined to offer coverage, non-renewed coverage or cancelled coverage for your firm?*

SUITS FOR FEES

How many suits for the collection of fees have you filed against your clients in the last 12 months?*

ADMINISTRATIVE CONTROLS

Maintain a Docket Control System with at least two independent date controls?*

Are two separate individuals involved in managing the system?*

Maintain a Conflict of Interest Avoidance system?*

Any attorney serve(d) as a Director/Officer, or have equity interest in a client?*

Any single client represent 10% or more of your firm’s total gross billings?*

Does the share common office space with another law firm?*

In the past five years, has your firm merged, been acquired, or experienced a change in membership of at least 50% of the firm’s attorneys?*

Number of support staff*

Does your Firm have a full-time legal administrator?*

Member of the Assoc. of Legal Administrators (ALA)?*

How many attorneys have participated in CLE during the last 12 months?*

Estimated annual gross revenue for this year*

Does your firm use non-engagement letters*

Does your firm use disengagement letters*

Does your firm use retainer agreements*

PERSONAL INJURY WORK

Is Personal Injury Law an area of pratice for your firm?*

REAL ESTATE PRACTICE

Is Real Estate Law an area of practice for your firm?*

ESTATE / TRUST / PROBATE PRACTICE

Is Estate / Trust / Probate Law an area of practice for your firm?*

MATRIMONIAL (DIVORCE) PRACTICE

Is Matrimonial or Divorce Law an area of practice for your firm?*

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Lawyer's Professional Liability Indication: Step 1 of 6