Attorney Professional Liability Indication Form
 
 
 
 
 
 
Firm Name*
 
 
 
 
Address*
 
 
City*
 
 
 
State*
 
 
ZIP Code*
 
 
 
Phone*
 
 
Email*
 
 
 
Date Established*
 
 
Full Time or Part Time?*
 
Full Time
Part Time
 
 
 
 
 
Do you currently have Professional Liability Insurance?*
 
Yes
No
 
 
 
If Yes:
 
Insurance Company
 
 
 
 
Retroactive Date
 
 
 
 
Expiration Date
 
 
Current Premium
 
 
 
Policy Limit
 
 
Deductible
 
 
 
How many years have you had continuous coverage?
 
 
 
 
 
 
 
Agency