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Lawyers Professional Liability - Ballpark Premium Estimate Request

By answering these few questions, we can offer you a reliable estimate of what coverage under the plan would cost. If you decide to buy coverage, we'll need a complete application.

Please Note: This Ballpark Premium Estimate Request is only valid for firms of 1 - 34 attorneys. If you have a larger firm, please contact our office to arrange for a preliminary proposal.

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Privacy Statement: Any information provided by a consumer or customer via our online forms WILL be held in the strictest confidence. No information will be shared with others. Our goal is to respond to all submissions within two business days.

We only accept inquiries for insurance written in New York State

About The Firm
Firm Name:
Contact Name:
Firm/Contact is:	Applicant Broker
Street Address:
City:	State: ZIP:
County:
Phone:	Fax:
Best time to call:	am pm
Email:
Website:

Attorney Information
Please provide the number of staff within your firm: Years = Years of Continuous Insurance of Counsel Attorneys Support Staff = paralegals, secretaries, etc...
Years	Avg. # hours per week				# Member NY State Bar Assoc.*	# Support Staff
Years	0	1 - 10	11 - 25	26+	# Member NY State Bar Assoc.*	# Support Staff
6+
5
4
3
2
1
<1
* Local Bar Association Membership not applicable.

Billable Hours
Please tell us what percentage of Billable Hours - not income - you spend in the following areas of practice: (Please express in whole numbers)
% of Time	Area of Practice	% of Time	Area of Practice	% of Time	Area of Practice
	Admiralty / Marine - Defense		Corporate Business Organization		Natural Resources / Oil & Gas
	Admiralty / Marine - Plaintiff		Criminal		Personal Injury / Property Damage - Plaintiff
	Anti-trust Trade Regulation		Environmental Law		Personal Injury / Property Damage - Defense
	Banking / Financial Institutions		Family Law		Real Estate / Title-Commercial
	Business Transaction / Commercial Law		Governmental Contracts / Claims		Real Estate / Title-Residential
	Civil / Comm'l Litigation - Defense		Immigration / Naturalization		Securities (SEC)
	Civil / Comm'l Litigation - Plaintiff		Intellectual Property (Patent, Trademark, Copyright)		Taxation
	Civil Rights / Discrimination		International Law		Wills, Estate, Probate & Planning
	Collection & Bankruptcy		Labor Management Representation		Workers' Compensation - Defense
	Construction (Building Contracts)		Labor Union Representation		Workers' Compensation - Plaintiff
	Consumer Claims		Local Government		Mass Torts / Class Actions

	Other: Please describe here:

TOTAL:					(Must total 100%)

Current Insurance Coverage
Note: Please leave blank if "none"
# of years continuously insured:	years
Current Prof. Liab. Carrier/Program:
Current Agent:
Current Limits:	Deductible: $
Please select:	Defense Inside 50% Offset Defense Outside
Additional Options Desired?:	Yes No
Current Policy Expiration Date:	Annual Premium: $
If your policy contains a retro-date, please list date here:
Does your policy contain individual prior acts dates for any attorneys?:	Yes No

Claim History
Have you had or reported any Professional Liability claims in the last five years?			Yes No
If yes, please provide additional information below:
	One	Two	Three
Date Claim(s) Reported:
Amount paid, incl defense expenses (if closed)	$	$	$
Reserve Amount (if open)	$	$	$
Date Claim(s) Closed
Note: Any open claims may require an updated loss run

Firm Operations and Management
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
If yes, are any of these clients financial institutions?	Yes No
Do you have written procedures in place to identify and disclose conflicts of interest?	Yes No
Has the firm initiated lawsuits or arbitration procedures during the last two years to enforce the collection of unpaid fees for the firm?	Yes No
If "Yes", how many?
Do you share office space with another attorney or firm?	Yes No
If yes, do you share letterhead with them?	Yes No
Does the firm regularly confirm representations via use of engagement letters?	Yes No

The fields below apply to Broker/Agent Proposal Requests ONLY!
Contact Name:
Agency Name:
Contact Phone:	Contact Fax:
Contact Address:
City:	State: Zip:
Contact Email:
This ballpark is for a current client of our agency:	Yes No

Additional Comments

Please give any additional comments about the coverage you desire:

Please click on the "Submit Request" button to send your request.
One of our representatives will respond to your submission as soon as possible.

PARSONS & ASSOCIATES

The Galleries of Syracuse
440 S Warren St Ste 704
Syracuse NY 13202-2656

GIVE US A CALL

Telephone: (315) 472-5420
Toll Free: (800) 440-9932
FAX: (315) 472-3222
Toll Free Fax: (877) 472-8465

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Please Note: This website is intended to present a general overview for illustrative purposes only. It is not intended to constitute a binding contract. Please remember that only the relevant insurance policy can provide the actual terms, coverages, amounts, conditions and exclusions for an insured. Insurance coverages may not be changed or added by email request. They must be confirmed by a representative from Parsons & Associates, Inc.