| Complete this form to receive
a premium estmate. Quotations and coverage may be issued
only upon
acceptance of a fully completed application. If you have
any questions, call Jamison Insurance Group
at 973-731-0806 or 800-JAMISON |
| To
which attorney in your firm should insurance matters be
addressed? |
| Contact
Name |
|
| Firm
Name |
|
| Address |
|
City |
|
| State |
|
Zip |
|
| Telephone |
|
Fax |
|
| E-Mail |
|
| |
Please
indicate, in the spaces below, the number of attorneys in
your firm according
to their years in practice: |
| Less
than 1 year |
|
1
year |
|
| 2
years |
|
3
years |
|
| 4
years |
|
5+
years |
|
| of
Counsel |
|
Total
Num of Attorneys |
|
| |
What
percentages of time (not income) do you spend in the following
practice specialties?
(Indicate % in whole numbers, total must equal 100%) |
| Anti-Trust/Trade
Regulation |
% |
Business
Transactions Commercial Law |
% |
| Collection
and Bankruptcy |
% |
Business
Transactions Entertainment |
% |
| Civil
Rights / Discrimination |
% |
Consumer
Claims |
% |
| Criminal |
% |
Family
Law |
% |
| Government
Contracts / Claims |
% |
Defense-Personal
Injury / Property Damage / Insurance |
% |
| Immigration
/ Naturalization |
% |
International
Law |
% |
| Local
Government |
% |
Wills,
Estates, Trust and Probate |
% |
| Workers
Compensation Defense |
% |
Admiralty
/ Marine |
% |
| Corporate
Business Mergers / Acquisitions |
% |
Corporate
Business Formations / Alterations |
% |
| Construction
(Building Contracts) |
% |
Environmental
Law |
% |
| Labor
Law |
% |
Natural
Resources / Oil & Gas |
% |
| Taxation |
% |
Intellectual
Property (Patent Trademark, Copyright) |
% |
| Personal
Injury / Property Damage-Plaintiff |
% |
Workers
Compensation Plaintiff |
% |
| Real
Estate / Title-Commercial |
% |
Banking
/ Financial Institutions |
% |
| Real
Estate / Title-Residential |
% |
Securities(S.E.C.) |
% |
| Other(Please
Explain) |
% |
Other(Explain
Here) |
|
| |
Have
at least half the attorneys in your firm had some type of
continuing legal education within last year? |
|
| |
| YOUR
CLAIM HISTORY |
| Have
you had or reported any claims in the last five years? |
|
| Date
Claim(s) Reported |
|
Amount
Paid, Including Defense Expenses(if Closed): |
$
|
| Reserve
Amount (If Open) |
$
|
| |
| YOUR
INSURANCE HISTORY |
| How
long have you been continuously insured? |
|
| Current
Malpractice Insurer |
|
Current
Expiration Date |
|
| Current
Renewal Premium |
$
|
Current
Limits of Liability |
$
|
| Current Deductible Amount |
$
|
Select One |
|
| |
| OUTSIDE
INTERESTS |
Does
any attorney in your firm serve as director, officer or
employee,
or have equity interest in any client of the firm? |
|
If
Yes, Please provide
a brief explanation |
|
| |
| INTERNAL PROCEDURES |
| Do
you have written procedures in place to identify and disclose
conflicts of interest? |
|
| Do
you have a docket system? |
|
| If
Yes, please describe |
|
  |