Professional Liability Worksheet (Part 1 of 2)
Please fill in the worksheet below and answer every question.  When you've finished, scroll down and "click" Submit
Contact Information (if you completed the registration form, fill in your contact name and skip to Firm Information)
    Contact Name
    Firm Name
    Street Address
    Mailing Address (if different)
    City
    State
    Zip
    Phone
    Fax
    Email
    Web Address
Firm Information
    Date Current Firms was established
    # of Attorneys
    Of the attorneys, how many are "Of Counsel"?
    # of Support Staff
    Is this a Full-Time Practice of Law?
Yes
No
    Estimated Annual Gross Income?
Internal Controls
    Do you maintain a Docket Control System with at least two independent date controls
No
Yes
    Is one Docket Control System computerized?
No
Yes
    Do you maintain a Conflict of Interest System?
No
Yes
    Do you use Engagement and Non-Engagement Letters on a regular basis?
No
Yes
Current Insurance
    Do you have Professional Liability Insurance now?
Yes
No
    If yes, complete the following
 
    Insurance Company (not Agency)
    Insurance Agency
    Limits Of Insurance (per occurrence/aggregate)
    Deductible
    Current Premium
    Retroactive or Prior Acts Date
    Renewal Date
    Date of first continuous claims made coverage
Claim & Discipline 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
    If "YES", how many?
    Has any member of the applicant firm been refused admission to practice,
    disbarred, suspended, reprimanded sanctioned or held in contempt by a court,
    administrative agency or regulatory body?
Yes
No
    If "YES", please provide details.
Areas Of Practice (fill in only the areas that are applicable)
Description
%
Description
%
Administrative
Investment Counseling/Money Management
Admiralty/Maritime - Defense
Loans
Admiralty/Maritime - Plaintiff  (1)
Labor Law - Management
Antitrust/Trade Regulation
Labor Law - Union
Arbitration/Mediation
Labor Litigation - Defense
Aviation
Labor Litigation - Plaintiff
Banking/Financial Institutions
Litigation - Commercial - Defense
Bankruptcy
Litigation - Commercial - Plaintiff
BI/PI - Defense
Mergers and Acquisitions
BI/PI Plaintiff
 
Municipal, Governmental - Zoning & Planning
    General Liability (1)
Municipal, Governmental - Other (Not Bonds)
    Medical Malpractice (1)
Oil, Gas, Minerals
    Products Liability (1)
Patent
    Other Plaintiff (1)
Public Utilities
Civil Rights/Discrimination
Real Estate - Commercial
Collection/Repossession/Foreclosures
Real Estate - Escrow Agent
Communication/FCC
Real Estate - Residential
Copyright/Trademark (Not Patent)
Real Estate - Title Work
Corporate - Formation/Alteration
Real Estate - Syndication, Development
Corporate - General
School Law
Criminal
Securities, Bonds, Secured Transactions
Domestic Relations/Family/Juvenile
Social Security, Elder Law
Eminent Domain
Tax - Corporate, Business Opinions
Employee Benefit Plans/ERISA
Tax - Corporate, Business Preparation
Entertainment/Sports
Tax - Individual
Environmental - General
Water Rights
Environmental - Litigation
Workers Compensation - Defense
Estate/Estate Planning/Probate/Trusts/Wills
Workers Compensation - Plaintiff
Foreign (Non-US Law)/International
Other - Describe in detail
 
Healthcare
Insurance
The above must total 100%
100%
Click the "Submit" button to send me what you've entered.
You'll then be sent to the last page of this form, "Lawyer Census"
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