Firm Information
Name _____________________________________________
Address ___________________________________________
City ______________________St____ Zip Code __________
Tel # ( ) ____________ Fax # ( ) ________________
E-Mail _________________________
Date the firm was Established ____/____/____
Estimated annual gross income: $________________________
A. Number of Attorneys “ Of Counsel”: ________
B. Number of Support Staff _____
Number of Attorneys
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Years of experience
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Attorneys
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5 + Years
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|
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4+ Years
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|
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3+ Years
|
|
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2+ Years
|
|
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1+ Year
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|
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Less than 6 months
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|
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Total
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|
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Internal Controls: Do you maintain a Docket Control system with at least two independent date controls?
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□ Yes □ No
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Is a Conflict of Interest System maintained?
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□ Yes □ No
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Are engagement letters used on a regular basis?
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□ Yes □ No
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Has any member of the applicant firm been refused
admission to practice, disbarred, suspended,
reprimanded, sanctioned, or held in contempt by the
court administrative agency or regulatory body?
If “YES”, please provide details.
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□ Yes □ No
|
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Claim History Are you aware of any claims against your firm or any incidents that could result in a claim against your firm within the past five years?
If “YES”, how many? ________
Please provide details of each claim or incident, including a description of the allegations, current reserve and/or indemnity.
|
□ Yes □ No
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Number of hours worked on behalf of your firm?
|
________
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Current Insurance
Insurance Company _______________________________
Policy Effective/Expiration Date ____/____/____
Retroactive/Prior Acts Date ____/____/____
Policy Limits $______________________
Deductible $ _____________________
Date of first continuous claims-made coverage ____/____/____
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This is not an Insurance Binder. The information provided on this form will be used to provide a premium indication. Final premium will be subject to the completion of an application.
Herbert H. Landy Insurance Agency, 75 Second Ave, Needham MA 02494. 1-800-336-5422Visit our website @ www.landy.com
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Area of Practice Percentag
(Percentages must total 100%)
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Administration
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_____%
|
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Admiralty/Maritime
|
_____%
|
|
Antitrust/Trade Regulation
|
_____%
|
|
Arbitration/Mediation
|
_____%
|
|
Banking/Financial Institutions
|
_____%
|
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Bankruptcy
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_____%
|
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BI/PI Defense
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_____%
|
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BI/PI Plaintiff
|
_____%
|
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Civil Rights/Discrimination
|
_____%
|
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Collection/Repossession
|
_____%
|
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Communication/FCC
|
_____%
|
|
Copyright/Trademark
|
_____%
|
|
Corporate-Formation
|
_____%
|
|
Corporate-General
|
_____%
|
|
Criminal
|
_____%
|
|
Domestic Relations/Family
|
_____%
|
|
Employee Benefits
|
_____%
|
|
Entertainment/Sports
|
_____%
|
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Environmental
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_____%
|
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Estates/Probate/Wills/Trusts
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_____%
|
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Foreign/International
|
_____%
|
|
Healthcare
|
_____%
|
|
Insurance
|
_____%
|
|
Investments/Money Mgmt
|
_____%
|
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Labor Law/Management
|
_____%
|
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Labor Law/Union
|
_____%
|
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Mergers & Acquisitions
|
_____%
|
|
Municipal
|
_____%
|
|
Oil/Gas/Minerals
|
_____%
|
|
Patent
|
_____%
|
|
Public Utilities
|
_____%
|
|
Real Estate/Commercial
|
_____%
|
|
Real Estate/Residential
|
_____%
|
|
School Law
|
_____%
|
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Securities
|
_____%
|
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Social Security/Elder Law
|
_____%
|
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Tax/Corporate
|
_____%
|
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Tax/Individual
|
_____%
|
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Water Rights
|
______%
|
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Work Comp/Defense
|
_____%
|
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Work Comp/Plaintiff
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_____%
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Other (describe):
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_____%
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Total
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100%
_______
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