PROFESSIONAL LIABILITY QUOTE FORM

Please complete the form below. Required fields have an asterisk next to them.

You may also print and fax to (303) 474-6921


*Firm Name:

*Contact Name:

Street Address:

City

State

Zip

*Telephone:

Fax:

*E-Mail

Date firm was established:

Current Insurance Information

Current Carrier:

Expiration Date:

Limits of Liability:

Prior Acts Date:

or None

Deductible:

Premium:

Areas of Practice: Please identify the Applicant Firm's areas of practice with the number representing the percentage of gross income derived from that area during the past year. The total of these must be 100%

% Administrative:

% Wills, Trusts & Estate Planning:

% Real Estate:

% Banking: %

% Estates Under $500 K:

% Commercial :

% Bankruptcy:

% Estates Over $500K:

% Residential :

% Collections:

% Immigration:

% Title Work:

% Contracts:

% Intellectual Property:

% Securities Law:

% Corporate Law:

% Copyright:

% Registrations:

% Director Fees:

% Patent:

% Private Placement:

% Formation/Alt.:

% Trademark:

% Opinions:

% License/Permits:

% Labor/Employment:

% PI/BI Plaintiff:

% M/A:

% Family Law:

% Med Mal:

% General Corp:

% Non-Divorce:

% Prod. Liab:

% Criminal:

% Divorce:

% Class Action:

% ERISA:

% Workers Comp:

% Other:

% Oil & Gas:

% Tax:

% PI/BI Defense:

% Municipal Law:

% Environmental:

% Commercial Matters:

Please list other areas of practice not included on this list and percentages of each on a separate sheet

Attorney Name

*O, OC, P, A, E

Date of Hire

Bar Admit Date

Hours worked/week

CLE Current (Y/N)

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

*O=Owner, OC= Of Counsel, P=Partner, A= Associate, E=Employee

Other areas of practice:

Explain a Claim:

1. Does your firm use:
Engagement Letters: YesNo
Termination Letters YesNo
Fee Agrmnts YesNo

2. Docket control system:
Computer Tickler Dual Calendar Day-timer Other

3. Is your system checked:
Daily Weekly Monthly

4. Does any member of your firm have greater than 10% interest in any company that is also a client?
YesNo

5. Conflict of interest system:
Computer Single Index Multi Index Conflicts of Interest Software

6. Has any attorney had a claim made against them in the past 5 years?
YesNo
(If 'yes' provide details)

7. Has any attorney been disbarred or reprimanded
YesNo
(If 'yes' provide details)

8. Please indicate the number of: Paralegals Secretary/Receptionist Contract Attorney

9. Does any attorney act as director, officer or employee of any client?
YesNo
(If 'yes' provide details)

10. Have you sued any client for failure to pay fees in the past 3 years?
YesNo
If yes, how many?