LawyerCare® Non-Binding Quick Quote for a Claims Made Policy
  • Navigate this form using your Tab key, click on Continue when finished.
  • All questions must be answered completely.
  • The application must be completed by a principal of the firm.
  • This quick quote is available in Indiana, Michigan and Ohio.
How do you want us to contact you with your Quick Quote?
Phone OR Fax OR Email
Are you working with an insurance agent or agency? Yes No
If yes, please provide name:

Firm Information

Firm Name:
Address listed on your letterhead:
City, State Zip: ,
Phone Number:
I understand this application provides a non-binding quote for coverage in Indiana, Michigan or Ohio only. ProAssurance Casualty Company does not provide LawyerCare coverage in any other state.
Do you have other office locations? Yes No   If yes, list each address
Year firm was established:
Number of lawyers in firm: Number of support staff:
Requested effective date:

Coverage Requested

Indicate limits of liability and deductible(s) requested:

Limits of Liability Deductible
$100,000 each claim/$300,000 aggregate None
$250,000 each claim/$750,000 aggregate $1,000 each claim
$300,000 each claim/$600,000 aggregate $2,500 each claim
$500,000 each claim/$1,500,000 aggregate $5,000 each claim
$1,000,000 each claim/$2,000,000 aggregate $10,000 each claim
$2,000,000 each claim/$4,000,000 aggregate $15,000 each claim
$3,000,000 each claim/$4,000,000 aggregate $20,000 each claim
$4,000,000 each claim/$4,000,000 aggregate $25,000 each claim
$5,000,000 each claim/$5,000,000 aggregate $50,000 each claim
Other: Other:

Coverage Options

Claim expense is included within the limit of liability and within the deductible. Additional limits for claim expense equal to the each claim limit up to $1,000,000 outside the limit of liability is available. Check here to request this option:
First Dollar Defense Coverage is available. Check here to request this option:

Current Coverage

Is your firm currently insured for professional liability? Yes   No
Retroactive Date Requested:
Is the firm comprised of any predecessor firms? Yes   No
If yes, list those firms where the applicant is a majority successor to the predecessor firm's assets and liabilities.
Name of Predecessor Firm(s) Date Established # Attorneys

Firm Practice Management

For the next six questions, pleas explain all "yes" responses in the additional space provided below.
Does any client or group of related clients make up 10% or more of your gross receipts? Yes   No
If yes, please explain:
Does your firm use any attorneys not listed on this application to provide legal services for your firm? Yes   No
If yes, list all such lawyers and describe their relationship to your firm.
Does your firm share office space, cases, or letterhead with another firm? Yes   No
If yes, list all such lawyers and describe their relationship to your firm.
Is any lawyer listed on the application an officer, director, shareholder or does any member or your firm exercise fiduciary control over an entity other than the applicant firm and is that entity a client of the firm? Yes   No
If yes, list all such lawyers and clients and describe their relationship.
Has any member of the firm been the subject of any reprimand or disciplinary action or refused admission to the bar or any bar association, court or administrative agency? Yes   No
If yes, please explain:
In the last 10 years has any member of the firm had a claim made against them or are they aware of any incidents, facts or circumstances that could result in a claim against the firm or predecessor firm? Yes   No
If yes, please complete the following:
In the event an incident is currently open, enter OPEN for the CLOSED DATE.
Individual Lawyer Incident Date Report Date Closed Date Amt. Paid
$
$
$
$

Space Provided for any additional information or claims:

Practice Profile

Percentages of billings given for each area of practice must equal 100%
Admiralty Governmental & Regulatory
Agent Practice/Entertainment Intellectual Property (Patent/TM)
Corporate & Finance Mass Torts/Class Action
Corporate Formation Mediation, Arbitration
Corporate Mergers & Acquisitions Medical Malpractice Defense
Corporate Private Placements Medical Malpractice Plaintiff
Creditor Rights/Bankruptcy Oil & Gas, Mineral Rights
Criminal Defense Plaintiff Litigation
Defense Litigation Securities
Employment Law Tax
Environmental Workers Compensation Defense
Estate, Trust & Probate Workers Compensation Plaintiff
Family Law Other:
General Litigation Other:
General Practice Other:

Individual Attorney Information

Name Registration # Date Admitted Date of Hire

Space Provided For Any Additional Information

Notice To Applicant

The premium quoted will be based upon the information provided in this request. Final premium determination will be made upon completion of a LawyerCare ® Professional Liability Application.
If you are aware of any incident, fact, circumstance, act or omission that could reasonably result in a professional liability claim against you or any lawyer listed in this application, you should immediately file a report with your current carrier.
I/we have disclosed the following number of claims
or incidents with this application:
Name and Title of Applicant   Date