P.O. Box 1726 - Carlsbad, CA 92018 
Phone: (760) 720-0110 or 1(888) QUOTE 18 Fax: (760) 720-0330

How would you like your premium estimate communicated to you?

Attorney Name

Designation Code

Year Admitted to the BAR

Date of Hire

Percent

Areas of Law

%

%

%

%

%

%

%

%

%

%

%

Does your firm have a computerized system with two docket controls?

Does your firm have a system to avoid conflict of interest?

Does your firm use engagement/disengagement or fee agreement letters?

In the past 5 years, has any firm member ever been subject to a disciplinary action, claim or suit?

Are you aware of any incident, negligent act, error, or omission that could result in a claim?

How many suits for fees or collection referrals has your firm filed in the past two years?

1 - Firm Information

2 - Current Insurance Information

Years of Continuous Professional Liability Coverage:

Limits Requested:

Deductible Requested:

3 - Attorney Information
(Please list all the Attorneys practicing on behalf of your firm)

4 - Areas of Law Practice
(Total must equal 100%)

5 - General Information

The Liability Place is an independently owned insurance brokerage which provides legal malpractice insurance. We use personal and business information only for insurance purposes only and we are committed to respecting your privacy. Information you provide will be used to provide insurance quotes requested by you, based on the information you have supplied. The information is only disclosed to effect or facilitate an insurance offer through insurance carriers or their representatives. If you do not wish to receive email, phone calls and/ or mailings from us in the future, please let us know in an email to brent@liabilityplace.com, or write to us at the address on top of the page or call us at 1-760-720-0110. Please be sure to include your name, address and phone, and we will be sure you are removed from the list.


(if NONE, proceed to step 3)

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