Firm Name: Contact Person:

Address: City/State: Zip Code:

Phone Number: Fax: Email Address:

Firm Information

1.  Have there been any changes in the name or ownership in the past twelve months? Y N 1a. Date Established
2.  # of Attorneys: # Of Counsel /Hours Worked Per Week # Of Support Staff
3.  # of Independent Contractors /Hours Worked Per Week
4. Please list the number of all attorneys in categories below as an expression of the number of years employed with firm
Less than 6 mo / 1 year / 2 years / 3 years / 4 years / 5 years + / TOTAL

Quality Controls

1.  Is “Docket System “computerized”? Y N
2.  Does it operate with 2 independent systems? Y N
3.  Are there 2 independent conflict of interest systems (COIS)? Y N 3a. Is the “COIS” computerized? Y N
4.  Does the Firm utilize Engagement, non-engagement and dis-engagement letters? Y N
5.  Has your firm sued for fees in the past 3 years? Y N If ‘yes’, how many?
6.  Has your firm engaged in any Mass Tort work or class action work in the last 5 years? Y N

Area of Practice Percentages

Administration / % / Domestic Relations/Family / % / Oil/Gas/Minerals / %
Admiralty/Maritime / % / Employee Benefits / % / Patent / %
Antitrust/Trade Regulation / % / Entertainment/Sports / % / Public Utilities / %
Arbitration/Mediation / % / Environmental / % / Real Estate/Commercial / %
Banking/Financial Institutions / % / Estates/Wills/Trusts / % / Real Estate/Residential / %
Bankruptcy / % / < 1MM / % / RE Development / %
BI/PI Defense / % / >1MM / % / School Law / %
BI/PI Plaintiff / % / Foreign/International / % / Securities / %
Civil Litigation / % / Healthcare / % / Social Security/Elder Law / %
Civil Rights/Discrimination / % / Insurance-Defense / % / Tax/Corporate / %
Class Action/Mass Tort / % / Insurance-Carrier Representation / % / Tax/Individual / %
Collection/Repossession / % / Investments/Money Mgmt / % / Water Rights / %
Communication/FCC / % / Labor Law/Management / % / Work Comp/Defense / %
Copyright/Trademark / % / Labor Law/Union / % / Work Comp/Plaintiff / %
Corporate-Formation / % / Medical Malpractice Plaintiff / % / Other (describe): / %
Corporate-General / % / Mergers & Acquisitions / % / Other (describe): / %
Criminal / % / Municipal/Bond / % / TOTAL: / 100 %
Claims History
1.  Are you aware of any claims against your firm or any incidents that could result in a claim against your firm within
the past 5 years? Y N If “Yes” how many? . Please provide Full details.
2.  Has any member of the application firm ever been refused admission to practice, disbarred, suspended, reprimanded,
sanctioned, or held in contempt by the court administrative agency or regulatory body or subject to any
Disciplinary complaint or grievance? Y N If “Yes” please provide Full details.
Current History
Effective Date: Insurance Company Limits: ( CEOL or CEIL)
Deductible: ( per claim or aggregate) Premium: $
Has your firm carried coverage on an uninterrupted basis for more than 5 years? Y N
Your Name: Date:

Please note this form is for proposal purposes only and does not bind any party in coverage.

15 Spinning Wheel Road * Suite 320 * Hinsdale, IL 60521 * 630 920-0160 * Fax 630 920-0163