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LAWYERS PROFESSIONAL LIABILITY INSURANCE PREMIUM INDICATOR (Risk Placement Services, Inc.)

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LAWYER’S PROFESSIONAL LIABILITY INSURANCE PREMIUM INDICATOR
Proposed Effective Date: From To
12:01 a.m. Standard Time at the address of the Applicant.
I. GENERAL INFORMATION
1. Applicant:
2. Street Address: City:
County:
St:
Zip:
3. Telephone Number: __________________________ Year Established: ________________________
II. APPLICANT’S PRACTICE
1. Practice Areas. Describe the Applicant’s practice by showing the approximate percentage of gross billable dollars
during the past year derived from the following:
CATEGORY A
CATEGORY B
Administrative
Government Law
International Law
Appellate
Title/Commercial
Juvenile
Arbitration Title/Residential
Labor/Management
Representation
Criminal
Traffic
Immigration
Mediation
Municipal Law
SUBTOTAL A
SUBTOTAL B
SUBTOTAL C
CATEGORY E
Civil Rights
Admiralty
Plaintiff: BI/PI
Foreign Law
Antitrust
Class Action or
Mass Tort
Guardianships Banking
Medical
Malpractice
Commercial Law
Other Litigation
Corporate Formation
Defense: Class Action
Foreclosures
Insurance
General Corporate Advice
(Excluding Med
Mal)
Lobbying
Medical
Malpractice
Tax Preparation
Other BI/PI
Other Litigation
SUBTOTAL D
SUBTOTAL E
SUBTOTAL F
CATEGORY H
Bankruptcy
Entertainment
Adoptions
Collection
Fiduciary
Environmental Law
Construction
Investment
Counseling
High Profile Divorce (greater
than 10 Million Marital Assets)
Estate Planning
Labor/Union
Representation
Limited Partnership
Formation
Estate, Trust, Wills
Mergers/Acquisitions
(Corporate)
Oil/Gas/Mining
Family Law
Purchase/sale of business
Real Estate Development
Patent,Trademark, Copyright
Litigation
Tax Opinions
SUBTOTAL G
SUBTOTAL H
SUBTOTAL I
CATEGORY K
CATEGORY L
Real Estate Syndication
Real estate
closings/general
Tribal Law
Securities / Bonds
Patent, Trademark,
Copyright Prosecution or
Searches
Water Law
SUBTOTAL J
SUBTOTAL K
SUBTOTAL L
2. ATTORNEYS
A) Please list the number of all attorneys in categories below as an expression of the number of years employed
by the Applicant Firm.
Less than 1 year
1 year
2 years
3 years
4 years
5 years +
TOTAL
B) Total “Of Counsel” or Independent Contractors ________ Include only “Of Counsels” or IC’s who average
working for you 20 hours or less per week.. (Otherwise, include in Category A.)
3. CURRENT COVERAGE
a. Insurance Company: _______________________________________________
b. Expiration Date:____________________ Retroactive Date (If applicable):____________
c. Premium:______________________ Limit:_______________ Deductible:____________
4. CLAIMS/CIRCUMSTANCES/DISCIPLINARY
a. Has any professional liability claim or suit been made in the past five (5) years against the firm or its
predecessor firm (s) or any current or former member of the firm or its predecessor firm(s)? Yes No
TOTAL NO. OF CLAIMS________
b. After inquiry, does any firm member know of any circumstance, situation, act, error or omission that could
result in a professional liability claim or suit against the firm or its predecessor firm(s) or any of the current or
former members of the firm or its predecessor firm(s)? Yes No
TOTAL NO. OF CIRCUMSTANCES________
If “Yes” to a. or b., please attach a copy of the Claim Supplement you completed for your current Insurer and
update as needed. Also, forward 5 year loss runs if available.
c. Has any current or former member of the firm ever been refused admission to practice, disbarred, suspended,
fined or held in contempt by any court, state or local bar association, administrative agency or regulatory
body? Yes No
If “Yes,” please provide full details.
5. SUITS FOR FEES
a. How many suits for collection of fees have been filed against firm clients in the last two (2) years? __________
6. ADMINISTRATIVE CONTROLS
a. Do you maintain a Docket Control System with at least two Independent date controls? Yes No
b. Is it computerized? Yes No
c. Do you maintain a Conflict of Interest Avoidance System? Yes No
d. Is it computerized? Yes No
e. Do you utilize engagement letters for all clients? Yes No
7. Please attach a copy of your letterhead
This form is for the purpose of providing your Firm with an estimate of premium cost. Coverage can only be
bound after a Markel Insurance Company application form is completed and accepted by the Company.
Please return this form to your insurance broker.
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Completed 23 November 2020

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