Premium Indication Form

PREMIUM INDICATION FORM

Firm:

E-MAIL Address:

Please give us your Business Address:
Address 1:
Address 2:
City:

State: ZIP/Postal Code:

Telephone:

Facsimile:

# of Attorneys: # of Of Counsel: Year Established:

What percentage of time

A.		C.
	% Admiralty		% Entertainment, sports or celebrity
	% Bankruptcy		% Oil, gas or mining
	% Collections		% Patent, copyright or trademark
	% Commercial and general corporate litigation		% Plaintiff's representation in personal or bodily injury
	% Criminal matter		% Plaintiff's representation in products liability
	% Defense of personal or bodily injury		% Plaintiff's representation in workers' compensation
	% Defense of products liability		% Real Estate
	% Defense of workers' compensation		% Real Estate
	% Taxation		% Title/Abstracting
	% Immigration		% Domestic Law
	% International Law
	% Mediation
	% Will, estate planning, probate
	% Subtotal (A)		% Subtotal (C)

B.		D.
	% Admiralty other than Defense		% Banking, savings & loan, or other financial
	% Corporation formation/alteration institution services		% Bonds, commercial paper, limited partnerships, or
	% Environmental		% Real Estate Syndication/Limited Partnerships
	% ERISA or Employee Benefits State or Federal securities, both exempt and non
	% Investment counseling/Money Mgt.
	% Labor
	% Labor management representation
	% Labor union representation
	% Mergers/Acquisitions		% Subtotal (D)
	% Taxation
	% Utilities
	% Other
	% Subtotal (B)		Total of A+B+C+D must equal 100%

Your Insurance History (if none check here) Please attach a copy of Declaration Page.

Current Malpractice Insurer:		Expiration Date:
Current Limits: $	Deductible: $		Premium: $
Retroactive Date (prior acts):			If full please check here

Your Firms Profile

1. Do you use different types of Client Communication Letters? Yes, No. If yes, how many

2. Do you have a Conflict of Interest Avoidance System? Yes, No.

3. Has your firm been established for at least five years and are the majority of its attorneys been in practice for more than five years? Yes, No.

4. Does your firm participate in at least four hours of CLE per attorney? Yes, No.

5. How many types of Docket Control Systems do you currently use?

6. Have you had or reported any claims in the last seven years? Yes, No. If yes, how many

Complete the attached Claim Supplement for each claim.

7. Does any attorney in your firm serve as a director, officer or employee or have any equity in any client of the firm? Yes, No.