Errors and Omissions Insurance

Preliminary Premium Indication Worksheet

Firm Name:*

Contact Name:*

Address:*

City:*

State:*

Zip:*

Phone:*

Fax:

Email:*

Firm Information

Date Practice Established:
# of "Of Counsel":
# of Support Staff:
# of attorneys (excl. OCs) and years with Applicant:
# of years # of Attorneys:
5+ years:
4 years:
3 years:
2 years:
1 year:
less than 6 months:
How many attorneys have participated in CLE during the past twelve months?:
Estimated annual gross income:

Internal Controls

Do you maintain a Docket Control System with at least two independent date controls?
Yes: No: Is a Conflict of Interest System maintained?
Yes: No: Are engagement and non-engagement letters used on a regular basis?
Yes: No:

Current Insurance

Carrier:
Limits & Deductible:
Premium:
Retroactive/Prior Acts Date:
Policy Term:
Date of first continuous claims-made coverage:

Claim History

Are you aware of any claims against your firm or any incidents that could result in a claim against your firm within the past five years?
Yes: No: Has any member of the applicant firm been refused admission to practice, disbarred, suspended, reprimanded, sanctioned, or held in contempt by the court administrative agency or regulatory body?
Yes: No:

Area of Practice Percentages (percentages must total 100%)

Administrative:	%
Admiralty/Maritime - Defense:	%
Admiralty/Maritime - Plaintiff:	%
Antitrust/Trade Regulation:	%
Arbitration/Mediation:	%
Banking/Financial Institutions:	%
Bankruptcy:	%
BI/PI - Defense:	%
BI/PI - Plaintiff:
General Liability:	%
Medial Malpractice:	%
Products Liability:	%
Other Plaintiff:	%
Civil Rights/Discrimination:	%
Collection/Reposession/Foreclosures:	%
Communication/FCC:	%
Copyright/Trademark (Not Patent):	%
Corporate - Formation/Alteration:	%
Corporate - General:	%
Criminal:	%
Domestic Relations/Family/Juvenile:	%
Eminent Domain:	%
Employee Benefit Plans/ERISA:	%
Entertainment/Sports:	%
Environmental - General:	%
Environmental - Litigation:	%
Estate Planning/Probate/Trusts/Wills:	%
Foreign (Non-U.S. Law)/International:	%
Healthcare:	%
Insurance:	%
Investment Counseling/Money Management:	%
Loans:	%
Labor Law-Management:	%
Labor Law-Union:	%
Labor Litigation - Defense:	%
Labor Litigation - Plaintiff:	%
Litigation-Commercial-Defense:	%
Litigation-Commercial-Plaintiff:	%
Mergers and Acquisitions:	%
Municipal/Governmental-Zoning & Planning:	%
Municipal/Governmental-Other (Not Bonds):	%
Oil/Gas/Minerals:	%
Patent:	%
Public Utilities:	%
Real Estate-Commercial:	%
Real Estate-Escrow Agent:	%
Real Estate-Residential:	%
Real Estate-Title Work:	%
Real Estate-Syndication/Development:	%
School Law:	%
Securities, Bonds, Secured Transactions:	%
Social Security/Elder Law:	%
Tax-Corporate/Business Options:	%
Tax-Corporate/Business Preparation:	%
Tax-Individual:	%
Water Rights:	%
Workers Compensation - Defense:	%
Workers Compensation - Plaintiff:	%
Other-Describe in Detail:	%
	THE ABOVE MUST TOTAL 100%

PLEASE NOTE: This worksheet is intended for the purpose of obtaining a Preliminary Premium Indication. In order for us to extend a firm Premium Quotation, a fully completed application and applicable supplements must be completed. Protection Advantage works through licensed and approved independent insurance agents. Someone will contact you shortly.