Serving Clients Since 1927

Omaha (402) 398-9009 | Kearney (308) 234-5258

Liability Insurance Form

Firm Name

PartnershipProfessional CorporationSole ProprietorOther

Contact

Telephone

Fax

Email Address (*)

Currently Insured?
YesNo

If yes, date of renewal:

Present Insurance Company

Premium

Limits

Deductible

Prior Acts Date

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

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

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

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

Number of suits

Does the firm utilize a computerized docket control system?
YesNo

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

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

Type of Practice (percentages)

Administrative Law

Banking

Bankruptcy/Collection

Civil Rights

Class Action/Mass Tort Plaintiff

Construction Law

Commercial Litigation - Plaintiff

Commercial Litigation - Defense

Copyright/Patent/Trademark/Intellectual

Corporate/Business Transaction

Corporate Mergers/Acquisitions

Criminal

Estate/Probate/Trust

ERISA

Family Law

Entertainment

Healthcare Law

Insurance Law

Mediation/Arbitration

Personal Injury - Defense

Personal Injury - Plaintiff

Real Estate - Residential

Real Estate - Commercial

Securities

Taxation

Workers Comp - Defense

Workers Comp - Plaintiff

Real Estate - Devel/Syndication

Other (specify)

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