Professional Liability Form

Lawyers Professional Liability

Firm Name

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Partnership
Professional Corporation
Sole Proprietor
Other

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Contact

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Telephone

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Fax

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Email Address (*)

This field must be filled out.

Currently Insured?

YesNo

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If yes, date of renewal:

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Present Insurance Company

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Premium

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Limits

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Deductible

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Prior Acts Date

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Please provide the number of attorneys and their years of experience:

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Does any attorney in the firm serve as a director, officer, employee or have an equity interest in any client?

YesNo

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What are the total CLE hours for all attorneys in the past 12 months?

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Have you filed any suits to collect fees in the past year?

YesNo

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Number of suits

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Does the firm utilize a computerized docket control system?

YesNo

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Has the firm had any Professional Liability claims in the past 5 years?

YesNo

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If yes, please indicate number of claims and amounts paid in damages and expenses.

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Type of Practice (percentages)

Administrative Law	Invalid Input
Banking	Invalid Input
Bankruptcy/Collection	Invalid Input
Civil Rights	Invalid Input
Class Action/Mass Tort Plaintiff	Invalid Input
Construction Law	Invalid Input
Commercial Litigation - Plaintiff	Invalid Input
Commercial Litigation - Defense	Invalid Input
Copyright/Patent/Trademark/Intellectual	Invalid Input
Corporate/Business Transaction	Invalid Input
Corporate Mergers/Acquisitions	Invalid Input
Criminal	Invalid Input
Estate/Probate/Trust	Invalid Input
ERISA	Invalid Input
Family Law	Invalid Input
Entertainment	Invalid Input

Healthcare Law	Invalid Input
Insurance Law	Invalid Input
Mediation/Arbitration	Invalid Input
Personal Injury - Defense	Invalid Input
Personal Injury - Plaintiff	Invalid Input
Real Estate - Residential	Invalid Input
Real Estate - Commercial	Invalid Input
Securities	Invalid Input
Taxation	Invalid Input
Workers Comp - Defense	Invalid Input
Workers Comp - Plaintiff	Invalid Input
Real Estate - Devel/Syndication	Invalid Input
Other (specify)	Invalid Input
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Contact

Omaha Office
P 402.398.9009 | P 800.284.7142
F 402.398.0917

Springfield Office
P 402.253.2399 | P 800.284.7142
F 402.398.0917

Kearney Office
P 308.234.5258 | P 800.284.7142
F 308.234.6802

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