Lawyers Price Indication Request

Price Indication Request

Please provide the requested information for a quick non-binding price estimate. This should take about 5 minutes to complete.

For assistance, please contact us at 844.398.0465 or info@LocktonAffinityLawyer.com

Firm Information

Note: Your privacy is very important to us. To better serve you, the form information you enter is recorded in real time.

Firm Name*

Email Address*

Name*

First Name

Last Name

Business Phone*

Number of Non-Attorney Staff*

Business Website*

Projected Annual Revenue* $

Are you a member of a Bar Association?

Yes No

Bar Association*

Firm Address

Address Line 1

Address Line 2

City

State

ZIP Code

County

Policy Information

Do you currently have a professional liability policy?

Yes No

Current Insurance Information

Expiration Date of Current Policy

Insurance Company Name

Current Insurance Premium $

Professional Liability Insurance Retro Date

Per Claim Limit Requested

Aggregate Limits Requested

Deductible Requested

Would you like a quote for cyber coverage?

Yes No

Claim Questions

1. In the past five years, has the firm or any attorney for whom coverage is sought ever been involved, directly or indirectly, in a claim, potential claim or suit arising out of the rendering or failing to render legal services?

Yes No

If yes for question 1, please explain. *

If "YES" to any questions above, please attach currently dated 5 year loss runs

No File Chosen

File uploads may not work on some mobile devices.

2. Is the firm or any attorney for whom coverage is sought aware of any act, error, omission or incident reasonably expected to result in a claim or suit being made against them?

Yes No

If yes for question 2, please explain.*

Loss Runs upload Document Type*

Excel Word Adobe PDF Other

3. Has the firm or any attorney for whom coverage is sought ever been disbarred, refused admission to practice law, suspended, reprimanded, sanctioned, fined, placed on probation, held in contempt or the subject of disciplinary action of any kind by a court, administrative or regulatory body?

Yes No

If yes for question 3, please explain.*

Firm Information

4. Has the firm filed against its own clients for the collection of fees in the past 5 years?

Yes No

If yes for question 4, please explain.*

5. Has the firm's coverage ever been non-renewed, cancelled, rescinded or declined by another carrier?

Yes No

If yes for question 5, please explain.*

6. Has the firm been involved in any mass tort/class action cases within the past five years?

Yes No

If yes for question 6, please explain.*

Does your law firm use a docket/calendar platform or system?

Yes No

Are there at least two independent controls, calendars or systems?

Yes No

Is one of these systems a computerized system ?

Yes No

Which conflict of interest procedures do you utilize?

Oral/memory Computerized Index file Client list Written procedures No system

Please select Yes or No for each statement.

Please select Yes or No for each statement.
	Yes	No
We use Engagement Letters for all new clients.	Please select Yes or No for each statement.: We use Engagement Letters for all new clients. (Yes)	We use Engagement Letters for all new clients. (No)
We use Engagement Letters on new matter for existing clients.	We use Engagement Letters on new matter for existing clients. (Yes)	We use Engagement Letters on new matter for existing clients. (No)
We use Non-Engagement Letters.	We use Non-Engagement Letters. (Yes)	We use Non-Engagement Letters. (No)
We use Disengagement Letters.	We use Disengagement Letters. (Yes)	We use Disengagement Letters. (No)

If "no" to any questions above, please provide additional information

Does the firm have any one client which represents more than 25% or more of the firm's billings?*

Yes No

If "yes", please provide additional information.

Areas of Practice

Next to the relevant area(s) of practice for your firm, please enter the percentage of your practice dedicated to each area. The percentage values should total 100. Feel free to leave the non-relevant areas blank.

Admiralty / Marine – Defense

Admiralty / Marine – Plaintiff

Anti-Trust / Trade Regulation

Banking / Financial Institutions

Bankruptcy

Business Transaction – Comm’l Law

Civil Rights / Discrimination

Civil/Comm’l Litigation – Defense

Civil/Comm’l Litigation – Plaintiff

Collections

Construction (Building Contracts)

Criminal

Environmental

Family Law

Government Contracts / Claims

Immigration / Naturalization

Intellectual Property (Copyright)

Intellectual Property (Patent)

Intellectual Property (Trademark)

International Law

Labor Management Rep

Labor Union Rep

Local Government

Natural Resources / Oil & Gas

Other

Personal Injury / Property Damage - Defense

Personal Injury / Property Damage - Plaintiff

Real Estate / Title - Commercial

Real Estate/ Title - Residential

Securities (S.E.C.)

Taxation

Wills, Estate, Trust & Probate

Workers' Comp - Defense

Workers' Comp - Plaintiff

Total

Please provide a quick description of this practice area*

Attorney Information

How many attorneys are employed at your firm? You can manually enter attorney data below for 1-5 attorneys or upload a roster.*

1-5 6-20 20+

Do you have an Attorney Roster to upload?

Yes No

Here’s a roster template for your use.

Attorney Roster Document Type

Excel Word Adobe PDF Other

Upload Attorney Roster

No File Chosen

File uploads may not work on some mobile devices.

If you choose to upload your Attorney Roster, please ensure the following is included for each attorney: full name, status (partner/associate), year bar exam was passed OR number of years in practice, states where attorney is admitted, date the attorney joined the firm OR retro date, hours worked per week. Please do not upload any sensitive data such as tax ID numbers, social security numbers, etc.

Attorney Roster

Attorney 1 - First Name

Attorney 1 - Last Name

Last Name

Attorney 1 - Status (Partner/Associate):

Attorney 1 - Year bar exam was passed OR number of years in practice:

Attorney 1 - States where attorney is admitted:

Attorney 1 - Date the attorney joined the firm OR retro date:

Attorney 1 - Hours worked per week:

Attorney 1 - Honors/Awards:

Attorney Roster

Attorney 2 - First Name

Attorney 2 - Last Name

Attorney 2 - Status (Partner/Associate):

Attorney 2 - Year bar exam was passed OR number of years in practice:

Attorney 2 - States where attorney is admitted:

Attorney 2 - Date the attorney joined the firm OR retro date:

Attorney 2 - Hours worked per week:

Attorney 2 - Honors/Awards:

Attorney Roster

Attorney 3 - First Name

Attorney 3 - Last Name

Attorney 3 - Status (Partner/Associate):

Attorney 3 - Year bar exam was passed OR number of years in practice:

Attorney 3 - States where attorney is admitted:

Attorney 3 - Date the attorney joined the firm OR retro date:

Attorney 3 - Hours worked per week:

Attorney 3 - Honors/Awards:

Attorney Roster

Attorney 4 - First Name

Attorney 4 - Last Name

Attorney 4 - Status (Partner/Associate):

Attorney 4 - Year bar exam was passed OR number of years in practice:

Attorney 4 - States where attorney is admitted:

Attorney 4 - Date the attorney joined the firm OR retro date:

Attorney 4 - Hours worked per week:

Attorney 4 - Honors/Awards:

Attorney Roster

Attorney 5 - First Name

Attorney 5 - Last Name

Attorney 5 - Status (Partner/Associate):

Attorney 5 - Year bar exam was passed OR number of years in practice:

Attorney 5 - States where attorney is admitted:

Attorney 5 - Date the attorney joined the firm OR retro date:

Attorney 5 - Hours worked per week:

Attorney 5 - Honors/Awards:

Do you have supplementary documentation to upload?

Yes No

File

No File Chosen

File uploads may not work on some mobile devices.

Supplementary Document Type

Excel Word Adobe PDF Other

CRMID