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Is the Firm currently insured?(Required)
MM slash DD slash YYYY
Do you want the cost of defense to reduce your limit of liability?(Required)
Attorney Name SC# Certified Specialist and/or 5 APC CLE within past 24 months Title Agent Full or Part-time Status Prior Acts/Retro Date Actions
           
If firm size is greater than five (5) attorneys, please complete a full application for a detailed quote.
*Part-time status is 25 hours a week or less.
**Prior Acts/Retro Date is the date said attorney first began carrying and continually renewing professional liability insurance coverage and is found in your current policy.
Has any attorney included in the quote either had a claim within the past 6 years OR been reprimanded, suspended (including voluntarily), or disbarred from practice before any court or administrative agency?(Required)
If your firm practices in any of the below areas of practice, please provide the estimated percentage(s) of practice in those areas:
Please enter a number less than or equal to 100.
Please enter a number less than or equal to 100.
Please enter a number less than or equal to 100.
Please enter a number less than or equal to 100.
Please enter a number less than or equal to 100.
Please enter a number less than or equal to 100.
Please enter a number less than or equal to 100.
Please enter a number less than or equal to 100.
Does your practice include any of the following areas of practice: 1. Probate Estates Trusts & Wills, 2. Family Law, 3. Employment, or 4. Bankruptcy?(Required)
THIS FORM IS USED TO GENERATE A NON-BINDING, BALL-PARK ESTIMATE, AND ADDITIONAL INFORMATION MAY BE REQUESTED BY YOUR UNDERWRITER. A COMPLETED APPLICATION FOR INSURANCE COVERAGE WILL BE REQUIRED FOR A BINDING QUOTE
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