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Broker Name *

Law Firm *

Managing Partner *

Establish Date *

Phone *

Email *

Address *

Number of Attorneys *

Number of "Of Counsel" *

Number of Support Staff *

Number of Attorneys (excl. OCs) and years at firm: *

1 year

Attorneys with 2 Years at the Firm *

2 years

Attorneys with 3 Years at the Firm *

3 years

Attorneys with 4 Years at the Firm *

4 years

Attorneys with 5 Years at the Firm *

5 years

Attorneys with 6 Years at the Firm *

6 years

Attorneys with 7 Years at the Firm *

7 years

Attorneys with 8+ Years at the Firm *

8+ years

How many attorneys have participated in CLE during the past twelve months? *

Estimated annual gross income *

Internal Controls

Do you maintain a Docket Control System with at least two independent date controls? *

Yes
No

Is a Conflict of Interest System maintained? *

Yes
No

Are engagement and non-engagement letters used on a regular basis? *

Yes
No

Is this a full time private practice of law? *

Yes
No

If Plaintiff litigation was performed, what is the largest judgement/settlement received in past 3 years? *

Yes
No

Current Insurance

Carrier *

Limits & Deductible *

Retroactive/Prior Acts Date

Policy Expiriation Date *

Date of first continuous claims-made coverage *

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? *

Yes
No

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? *

Yes
No

Area of Practice Percentages

(percentages must total 100%)

Admiralty/Marine

Antitrust/Trade Regulation

Arbitration/Mediation

Banking

Bankruptcy

Bodily Injury/Defense

This should be the sum of the three Bodily Injury/Defense subcategories below.

Bodily Injury/Defense – Medical Malpractice

Bodily Injury/Defense – Products

Bodily Injury/Defense – Class Action

Collection

Copyright – TM

Copyright – Patent

Corporate

Criminal

Domestic Relations

Entertainment

Environmental

ERISA

Est. Planning/Probate/Trusts/Wills (less than $1M)

Est. Planning/Probate/Trusts/Wills ($1M-$5M)

Est. Planning/Probate/Trusts/Wills ($5M+)

Government/Municipalities

Immigration

International Law

Investment Counseling

Labor Relations

Real Estate – Residential

Real Estate – Commercial

Real Estate – Synd Devel.

Real Estate – Title Work

Securities/State & Federal (SEC)

Securities – Private Placement

Securities – Bonds

Social Security Disability

Tax Preparation

Tax Opinions

Workers Comp/Defense

Workers Comp/Plaintiff

Other

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Internal Controls

Current Insurance

Claim History

Area of Practice Percentages