Lawyer Application

General Information About Your Firm

Firm Name*

Date Firm Established*

Defense Inside / Outside*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Contact Name*

Contact Email*

Current Carrier*

Effective Date*

Retroactive Date*

Limit of Liability*

Deductible*

Premium*

Staffing

Attorney List*

Please provide us with a list of attorneys in your firm. Click on the "+" button to add additional attorneys.

Name	Designation	Bar Admit Date	Date Joined firm	Hours per Week

Total Number of Support Staff*

Specialties

Areas of Practice*

Please complete the section below based on the last 12 months of gross revenue. Simply select the area of practice that represent your firm, then fill in the percentage of gross revenue for each area. Total percentage allocated should equal 100%

Administrative Law Percentage of Gross Revenue*

Appellate Law Percentage of Gross Revenue*

Arbitration / Mediation*

Banking / Financial Institutions Percentage of Gross Revenue*

Bankruptcy Percentage of Gross Revenue*

Business Transactions Percentage of Gross Revenue*

Civil Litigation Percentage of Gross Revenue*

Civil Rights Percentage of Gross Revenue*

Collections Percentage of Gross Revenue*

Commercial Litigation - Plaintiff Percentage of Gross Revenue

Commercial Litigation - Defense Percentage of Gross Revenue

Construction Law Percentage of Gross Revenue*

Copyright / Trademark Percentage of Gross Revenue*

Corporate Formation*

Corporate Mergers / Acquisitions*

Criminal Law Divorce Percentage of Gross Revenue*

Elder Law Percentage of Gross Revenue*

Entertainment Law Percentage of Gross Revenue*

Environmental Law Percentage of Gross Revenue*

ERISA / Employee Benefits Percentage of Gross Revenue*

Estate / Probate-General Percentage of Gross Revenue*

Family Law Percentage of Gross Revenue*

General Corporate Percentage of Gross Revenue*

Government Contracts Percentage of Gross Revenue*

Guardianship / Juvenile Percentage of Gross Revenue*

Immigration Percentage of Gross Revenue*

Insurance Defense Percentage of Gross Revenue*

Intellectual Porperty-Patent Percentage of Gross Revenue*

Labor-employee / Union Labor Percentage of Gross Revenue*

Management Percentage of Gross Revenue*

Land Use-Zoning

Local Government Percentage of Gross Revenue*

Municipal Law Percentage of Gross Revenue*

Natural Resources / Mining Percentage of Gross Revenue*

Oil / Gas / Mineral Rights Percentage of Gross Revenue*

PI/BI - Defense Percentage of Gross Revenue*

PI/BI - Plaintiff Percentage of Gross Revenue*

PI/BI - Plaintiff-Med. Malpractice Percentage of Gross Revenue*

PI/BI - Class Action / Mass Torts Percentage of Gross Revenue*

Public Utilities Percentage of Gross Revenue*

Real Estate - Commercial Percentage of Gross Revenue*

Real Estate - Residential Percentage of Gross Revenue*

Schools / Education Percentage of Gross Revenue*

Securities / Bonds Percentage of Gross Revenue*

Securities - Private Placement Percentage of Gross Revenue*

Social Security Percentage of Gross Revenue*

Taxation Percentage of Gross Revenue*

Traffic Percentage of Gross Revenue*

Water Law Percentage of Gross Revenue*

Wills / Trusts Percentage of Gross Revenue*

Workers Comp - Defense Percentage of Gross Revenue*

Workers Comp - Plaintiff Percentage of Gross Revenue*

Other Area of Practice*

Please tell us what other areas your practice works in.

Other Area of Pracrice Percentage of Gross Revenue*

Additional Area of Practice*

Additional Area of Practice Percentage of Gross Revenue*

Additional Questions

Any claims, incidents, or complaints in the past 5 years?

Yes
No

Provide detail for claims, incidents or complaints*

Dual Calendar cross-checked at least weekly by two indiviuals?*

Yes
No

Computerized docket system?*

Yes
No

Use engagement letters outlining scope of representation for new clients?

Yes
No

Use declination, termination, and non-representation letters as necessary?

Yes
No

Any lawyer serve as director, officer, or employee for current / former clients?

Yes
No

Any lawyer have an equity interest with current / former clients?

Yes
No

Please provide details on equity interest with current / former clients.*

Do you have a conflict of interest procedure in place?

Yes
No

Have you ever filed suit for fees?

Yes
No

Please provide details about filing suit for fees.*

What brought you to CCIG?

Thank you for your interest in obtaining coverage through CCIG. Please review your responses and click on submit to request a quote.

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Lawyer Application