Paragon Underwriters

Any
Questions?

Call us toll-free at:

1-800-727-0001

Insurance available in Michigan and Illinois only

Lawyers Professional Liability Insurance Quick Indication Form

Please complete this short application and submit it for processing. One of our representatives will contact you shortly with your premium indication.

* denotes required field

* Firm Name:
* Year Established:
* Street Address:
* City:
* County:
* State:	* Zip:
* Contact Person:
Website:
* Email:
* Phone:
* Fax:
* Do you currently have professional liability coverage?	Y N
* Current Policy Expiration Date:	/ /

Area of Practice

Please enter your firms area of practice based upon the percentages of gross billable dollars derived from each area in the last fiscal year. If you are a new firm, please estimate the areas of practice that you anticipate your gross billings to be derived from in the upcoming year.

Admiralty/Marine - Defense:	%	Immigration/Naturalization:	%
Admiralty/Marine - Plantiff:	%	Intellectual Property - Copyright/Trademark:	%
Antitrust/Trade Regulation:	%	Intellectual Property - Patents:	%
Banking / Financial Institutions:	%	International Law:	%
Business Transactions - Commercial Law:	%	Labor Management Representation:	%
Civil/Commercial Litigation - Defense:	%	Labor Union Representation:	%
Civil/Commercial Litigation - Plantiff:	%	Local Government:	%
Civil Rights/Discrimination:	%	Natural Resources/Oil & Gas:	%
Collection:	%	Other (Please Specify):	%
Bankruptcy - Creditors:	%	Personal Injury / Property Damage - Defense:	%
Bankruptcy - Debtors:	%	Personal Injury / Property Damage - Plaintiff:	%
Construction Law (Building Contracts):	%	Real Estate/Title - Commercial:	%
Consumer Claims:	%	Real Estate/Title - Residential:	%
Corporate - Business Organization:	%	Securities (S.E.C.):	%
Criminal:	%	Taxation:	%
Environmental Law:	%	Wills, Estate, Trust & Probate:	%
Family Law:	%	Workers Comp - Defense:	%
Government Contracts/Claims :	%	Workers Comp - Plaintiff:	%
		* Total must equal 100%	%
		remainder:	%

Current Coverage
Carrier:
Policy Expiration Date:	/ /
Retroactive/Prior Acts Date:	/ /
Limits:
Deductible:
Premium:
Coverage Type:	Claim Expenses Outside the Limits First Dollar Defense Per Claim Deductible Aggregate Deductible

Attorney List

Attorney Names	Designation	Year Attorney Joined Firm	Date First Continually Insured	States Licensed to Practice Law
* 1:
2:
3:
4:
5:
6:

Questions

* Number of Claims/Suits/Incidents Filed Against Firm in the Past 5 Years:
* Number pending:
* Number of suits for fees in the last 2 years:
* Number of practicing attorneys:
* Number of attorneys working less than 1000 hours/year:
* Is the firm aware of any circumstance(s) or act(s) which may give rise to a claim?	Y N
* Has any attorney with the firm ever been disciplined or denied the right to practice?	Y N
* Do you maintain a Docket Control System with at least two independent data controls?	Y N
* Is a Conflict of Interest System maintained?	Y N
* Are engagement and non-engagement letters used on a regular basis?	Y N
* Have you had continuous coverage for the past 5 years?	Y N
* Does the firm share office space with another law firm?	Y N
* Is the firm involved with any Mass Tort/Class Action cases?	Y N
* How did you hear about us:

Limits & Deductible

Additional Interests

Details - Any Comments/Questions

READ THIS: NO COVERAGE WILL BE BOUND without a completed signed application. Completing this form will only get you a premium indication and nothing more.

Submitting this form does not guarantee that a policy will be issued. Coverage may be bound with a fully completed application which has been approved with the offer of a firm quotation of terms.

* Please check this box to indicate that you understand the terms:

* I authorize Paragon Underwriters to use the information provided to research professional liability insurance quotes on my behalf:

Insuring Today's Professional

Any Questions?

Call us toll-free at:

1-800-727-0001

Any
Questions?