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Home > Malpractice > Lawyers Online Indication Form
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Lawyers Online Indication Form


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

  • General
  • Current Policy Information
  • Attorney Information
  • Areas Of Practice
  • Firm Details
General Information
Firm Name *
Year Established
Street *
City *
County
State *
ZIP / Postal Code *
First Name *
Last Name *
Primary Phone Number *
Fax
E-Mail Address *
Application Upload
Current Policy Information
Current Coverage *

Policy Expiration Date
/ /
Exclusion Date Retroactive or "Prior Acts Date"
/ /
Current Limits
Current Deductible
Deductible Type
Optional Coverages


Hold down the Ctrl Key to make multiple selections.
Current Insurance Carrier
Years of Continuous Coverage
Premium
Current Policy Declarations Page Upload
Attorney Information
Attorney 1
Name of Attorney 1 *
Attorney 1 Date Began Private Practice
/ /
Attorney 1 Date Joined Firm
/ /
Attorney 1 Status
Attorney 1 Hours Worked per Week
Attorney 1 Individual Retroactive Date
/ /
Attorney 2
Name of Attorney 2
Attorney 2 Date Began Private Practice
/ /
Attorney 2 Date Joined Firm
/ /
Attorney 2 Status
Attorney 2 Hours Worked per Week
Attorney 2 Individual Retroactive Date
/ /
Attorney 3
Name of Attorney 3
Attorney 3 Date Began Private Practice
/ /
Attorney 3 Date Joined Firm
/ /
Attorney 3 Status
Attorney 3 Hours Worked per Week
Attorney 3 Individual Retroactive Date
/ /
Attorney 4
Name of Attorney 4
Attorney 4 Date Began Private Practice
/ /
Attorney 4 Date Joined Firm
/ /
Attorney 4 Status
Attorney 4 Individual Retroactive Date
/ /
Attorney 5
Name of Attorney 5
Attorney 5 Date Began Private Practice
/ /
Attorney 5 Date Joined Firm
/ /
Attorney 5 Status
Attorney 5 Hours Worked per Week
Attorney 5 Individual Retroactive Date
/ /
Areas Of Practice: Provide percentages of time devoted during the previous year in each area of practice (Must Total 100%)
General Practice Areas
Admiralty/Marine – Defense
Admiralty/Marine – Plaintiff
Anti-Trust/Trade Regulation
Arbitrator/Mediator
Banking/Financial Institutions
Bankruptcy
Civil Rights/Discrimination
Collections
Construction (Building Contracts)
Consumer Claims (not class action)
Criminal
Entertainment/Sports money mgmt
Entertainment/Sports No money mgmt
Environmental Law
ERISA/Pension/Employee Benefits
Govt. Contracts/Claims
Healthcare – Regulatory Compliance
Immigration/Naturalization
Intellectual Property
International Law
Labor/Employment – Management
Labor/Employment – Employee
Labor/Employment – Union
Lobbying
Local Govt./Municipal (not bonds)
Natural Resources/Oil & Gas
Other (please describe)
Other Desc.
Business Transactions/Corp. Law
Administrative
Formation of Entities
General Contract Negotiation
Mergers & Acquisitions
Secured Transactions
Family Law
Adoption
Divorce – Marital Assets < 1M
Divorce – Marital Assets > 1M
Elder Law
Guardianship/Juvenile
Social Security
Litigation
Class Action/Mass Tort – Defense
Class Action/Mass Tort – Plaintiff
General Commercial – Defense
General Commercial – Plaintiff
Insurance Defense
Personal Inj./Prop Damage – Defense
Personal Inj./Prop Damage – Plaintiff
Personal Inj/Med Mal -Plaintiff
Work Comp – Defense
Work Comp – Plaintiff
Real Estate
Abstracting/Title – Commercial
Abstracting/Title – Residential
Conveyance – Commercial
Conveyance – Residential
Foreclosures & Loan Workouts
Landlord/Tenant
Syndications/Ltd. Partnerships
Zoning & Planning
Taxation
Business
Individual
Tax Litigation
Opinions
Wills, Estate, Trust, Probate
For assets < 1M
For assets > 1M
Does the firm have a docket system with two independent date controls?

Do you have a conflict of interest avoidance system?

Do you use engagement/disengagement letters?

How many times has your firm sued a client for fees in the last 2 years?
Total number of employees including attorneys
Firm Gross Revenue
Any Professional Liability claims or incidents reported against any of the attorneys’ listed, prior partners or associates in the last 5 years?

Is the firm aware of any circumstance(s) or act(s) which may give rise to a claim?

Have any of the firm's attorneys been the subject of any disciplinary action, for any reason other than non-payment of dues, within the last 5 years?

Claim Description
NOTE: This Form is for Estimate Purposes Only. Coverage May Be Bound Only Upon Submission and Acceptance of a Completed Application
Submission Validation
Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
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2430 Camelot Ct SE
Grand Rapids, MI 49546
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Toll Free: 866.940.1101
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