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1- Firm Information

Firm Name:*		Contact Name:*
Address:*		City:*
State:*		Zip:*
Phone:*		Fax:*
E-mail:*

How would you like your premium estimate communicated to you?
Phone E-mail Fax Any

2- Current Insurance Information

Current Carrier:* (if NONE, proceed to step 3)
Policy Expiration Date:* MM/DD/YY
Limits Requested:*
Deductible Requested:*
Years of Continuous Professional Liability coverage:*
Current Premium:

3- Attorney Information

(Please list all the Attorneys practicing on behalf of your firm)

Attorney Name	Designation Code	Year Admitted to the BAR	Date of Hire

4 - Areas of Law Practice

(Total Must Equal 100%)

Percent	Areas of Law
%
%
%
%
%
%
%
%
%
%
Total %
*A brief description of services rendered may be requested

5 - General Information

Does your firm have a computerized system with two docket controls?
Yes
No

Does your firm have a system to avoid conflict of interest?
Yes
No

Does your firm use engagement/disengagement or fee agreement letters?
Yes
No

In the past 5 years, has any firm member ever been subject to a disciplinary action, claim or suit?
Yes
No

Are you aware of any incident, negligent act, error, omission that could result in a claim?
Yes
No

How many suits for fees or collection referrals has your firmed filed in the past 2 years?

Privacy Policy
The Liability Place is an independently owned insurance brokerage which provides legal malpractice insurance. We use personal and business information only for insurance purposes only and we are committed to respecting your privacy. Information you provide will be used to provide insurance quotes requested by you, based on the information you have supplied. The information is only disclosed to effect or facilitate an insurance offer through insurance carriers or their representatives. If you do not wish to receive email, phone calls and/ or mailings from us in the future, please let us know in an email to brent@liabilityplace.com, or write to us at the address below or call us at 1-760-720-0110. Please be sure to include your name, address and phone, and we will be sure you are removed from the list.

4705 Marina Dr., Ste.12 Carlsbad, CA 92008 Phone: (760) 720-0110 or 1(888) QUOTE 18 Fax: (760) 720-0330