Affinity Insurance Agency, Inc.
Lawyers Professional Liability Form
TO: Affinity Insurance Agency
3950 Cobb Parkway, Suite 707
Acworth, GA 30101 		Tel. 770-974-5502
Fax 770-974-5359
PREMIUM ESTIMATE
Just give us a few facts about your firm and we can provide you with a premium estimate. We will need to see a fully completed application before we can send you a firm quote, but this should be enough information for reasonably good estimate
1.- Contact Person:
Firm:
Phone:
Email:

Address:
City: State: Zip:
Fax:
Website:

Consent Form: By entering my firm name, fax number (s), and my name above, I am authorized to and consent to the firm receiving faxes sent by or on behalf of Affinity Insurance Agency, Inc.
2.-Provide the number of attorneys and their years with your firm based upon their date of employment.
Number of Attorneys:
7 + years
6 + years
5 + years
4 + years
 3 + years
2 + years
1 + years
< 1 year
Gross Revenue:
Date Passed Bar Exam if less than 5 years ago.
(Please list all attorneys with their information below)
Date firm Founded:
3.-Have at least half the attorneys in your firm had some type of continuing legal education within the last year? YES NO

4.-What percentage of time – not income – do you spend in the following specialties?
(Total must equal 100%)
Admiralty/Defense %
Bankruptcy %
Collections %
General/Commercial Litigation %
Criminal %
Defense/Personal Injury %
Defense/Workers Compensation %
Defense/Products Liability %
Divorce w/Assets <$1M %
Divorce w/Assets $1M-5M %
Divorce w/Assets >$5M %
Immigration %
International Law %
Mediation %
Will/estate planning/probate %
Admiralty other than Defense %
Corporation Formation/Alteration %
Environmental %
ERISA or Employee Benefits  %
Investment Counseling/Money Mgt. %
Labor/Employee relations %
Labor management representation %
Labor Union representation %
 Entertainment/Sports/Celebrity %
Oil, Gas, Mining %
Patent/Copyright/Trademark %
Plaintiff/Personal Injury %
Class Action %
MedMal %
Plaintiff/Workers Compensation %
Plaintiff/Products Liability %
Real Estate/Commercial %
Real Estate/Residential %
Real Estate-Title/Abstracting %
Social Security %
Taxation/Individual %
Taxation/Corporate %
Utilities %
Banking/Savings & Loan, or other Financial Institution Services %
Bonds, Commercial Paper, Limited Partnerships or Federal Securities %
Real Estate Syndication/Limited Partnerships %
Mergers/Acquisitions %
Other* %

Total must equal 100%
5.-Do you use engagement letters for all clients?
6.-Does your firm have at least two (2) independently maintained calendars? YES NO
7.- a) Have you had or reported any claims within the last seven (7) years? Yes No

If yes how many?: One Two Three Four

If yes, Please give a brief description of the claim including date claim(s) reported, amount  paid including defense expenses (if closed) and reserve amount (if open)

  b) Bar Complaints: Number: Year   Closed:   Open:
8.-Current Malpractice Insurer:
Retroactive Date of Policy:
Current Deductible: 		Expiration Date of Policy:
Current Limits of Liability:
Current Premium:
9.-Limits of Liability Desired: Deductible Desired:
10.-Does any attorney in your firm serve as director, officer or employee, or have any equity interest, in any client of the firm? YES NO
11.-Number of Suits for Fees in the last 24 months:
    If more than three (3), an explanation must be add below.
    Please explain:
12.- Are you interested in an office package? YES NO
13.- Workers’ Comp?


3950 Cobb Parkway, Suite 707 Acworth, GA 30101
Tele. (770) 974-5502 * Fax (770) 974-5359
September 2007