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Select Google Internet Bar Journal Friend or Referral Mailer ext. 108 Mailer ext. 109 Mailer ext. 110 Mailer ext. 111 Mailer ext. 111 Mailer ext. 112 Other *Firm Name *Your Name Mr. Mrs. Miss Bar Number ARDC number in IL Date Licensed Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year Before 1960 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Additional States? None AZ CO GA IA IL IN KS KY MA MD MI MN NJ NM OH PA TN VA WA WI *Address   *City *County *State Select AZ CO GA IA IL IN KS KY MA MD MI MN NJ NM NY OH PA TN VA WA WI   *Zip   If your state is not listed above, we are currently unable to offer you a quote. *Email *Phone Fax Please list the names of the attorneys currently employed by your firm, including their dates of hire: Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year Before 1985 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Date Licensed Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year Before 1960 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year Before 1985 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Date Licensed Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year Before 1960 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year Before 1985 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Date Licensed Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year Before 1960 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year Before 1985 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Date Licensed Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year Before 1960 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year Before 1985 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Date Licensed Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year Before 1960 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year Before 1985 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Date Licensed Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year Before 1960 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Help us confirm that your firm qualifies for coverage by selecting the statements that apply to your firm. Firm Profile    No lawyer in our firm has ever been disbarred, reprimanded, suspended from practice or refused admission to practice before any Bar Association, Court or Administrative Agency which regulates the practice of law.    Within in the past five years, no professional negligence claims have been made against my firm or any of its current or past lawyers while part of this firm. None of the lawyers at our firm has knowledge of any situation which might result in a claim made against this firm or any member of it. (Certain claim situations may still qualify you for coverage.) Do you practice Part time? Yes*  No *If yes, please complete the following:       Average # of hours per week       Length of time you have been working these hours: Weeks Months Years Estimate the percentage of hours per year you work in each area of practice. (NOTE: Must total 100%) Percentage Areas of Practice  % Admiralty & Marine  % Agent Practice / Entertainment Law  % Business Formation  % Business Transactions - General  % Civil Litigation - General  % Commercial and Corporate General Lit. - Defense  % Commercial and Corporate General Lit. - Plaintiff  % Corporate Finance  % Creditor Rights / Collections  % Creditor Rights / General  % Criminal Defense  % Defense Lit. - Insurance Carrier Representation  % Divorce  % Elder Law  % Employee Benefit Plans, ERISA  % Employment Law - Employee Representation  % Employment Law - Management Representation  % Employment Law - Union Representation  % Environmental Regulatory  % Estate & Probate - General  % Estate Planning and Trust Administration  % GAL  % Immigration  % Intellectual Property  % Juvenile  % Mediation, Arbitration  % Mergers & Acquisitions  % Municipal – General (not finance)  % Municipal Finance or Bonds  % Oil & Gas, Mineral Rights  % Plaintiff Lit. - Class Actions  % Plaintiff Lit. - Legal Malpractice  % Plaintiff Lit. - Medical Malpractice  % Plaintiff Lit. - Personal or Bodily Injury  % Plaintiff Lit. - Social Security, Workers Compensation  % Public Utilities (not finance)  % Real Estate Finance  % Real Estate Residential & Basic Commercial  % Schools & Education (not finance)  % Securities/Private Placements/Public Registrations- # of investors  % Tax Preparation - Individual  % Taxation (excluding estate tax & individual tax preparation)  % Other: (if more than 5%, explain below) No lawyer, while in our firm, has:    provided or will provide legal services in exchange for stock, partial ownership or investment in a client or our firm; AND none of the lawyers in our firm now has or has had any other financial interest in, or served as a board member of, any 'for profit' client of our firm;    provided or will provide legal services for securities transactions (either registered or exempt), bonds, public offerings or real estate syndications;    served or will serve as general counselor or as a board member of a financial institution;    My firm uses a calendaring system which schedules client matters in more than one place, AND my firm has a system in place to avoid conflicts of interest in client representation. My Firm: does not currently have professional liability insurance does currently have professional liability insurance; Current Insurer: Reason for leaving: Policy Limits: Claims expenses inside limits of policy Claims expenses outside limits of policy (CEOL) what's this? Per claim / Annual Aggregate $100,000 / $300,000 $250,000 / $750,000 $300,000 / $300,000 $300,000 / $600,000 $500,000 / $1,500,000 $1,000,000 / $2,000,000 $2,000,000 / $4,000,000 $3,000,000 / $4,000,000 $4,000,000 / $4,000,000 $5,000,000 / $5,000,000 Deductible: $0 $1,000 $2,500 $5,000 $7,500 (Not available to solos) $10,000 (Not available to solos) Current policy expires on: Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 39 30 31 Year 2007 2008 Retroactive date/prior acts date provided by current policy: Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 39 30 31 Year 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Current premium is: $400 - $1,000 annually $1,000 - $1,500 annually $1,500 - $2,000 annually $2,000 - $2,500 annually $2,500 - $3,000 annually $3,000 - $3,500 annually $3,500 - $4,000 annually $4,000 - $4,500 annually $4,500 - $5,000 annually More than $5,000 annually My practice is: Full Time Part Time 10-25 hours per week average Part Time >10 hours per week average Any additional Comments or Questions: