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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