Premium Indication Form

Thank you for your interest in a Colorado Bar Association quotation. Please download and complete the PDF form and email it back to sw.lplsubmissions@hubinternational.com or fax to 866-243-0727.

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Firm Name:   Firm Contact Person:
Street Address:   Website Address:
City:   State:
Zip:   County:
Contact Email Address:   Phone:
Fax:    

Areas of Practice

 
% Administrative   % Real Estate - Commercial
% Bankruptcy   % Taxation
% Collections   % Wills/Estate/Probate/Trust
% Commercial & Corporate General Lit. - Defense   % Workers' Compensation - Defense
% Commercial & Corporate General Lit. - Plaintiff   % Banking Services
% Corporate Formation/Alteration   % Environmental
% Criminal   % SEC/State Securities
% Family Law   % Entertainment, Sports or Celebrity
% Immigration   % Investment Counseling/Money Management
% Mediation/Arbitration   % Mergers/Acquisitions
% Personal or Bodily Injury - Defense   % Oil, Gas or Mining
% Personal or Bodily Injury - Plaintiff   % Patent/Copyright/Trademark
% Real Estate - Residential   % Other 

Current Insurance Information

 
Carrier:   Expiration Date:
Retroactive Date:  
                  
Limits of Liability:   Deductible $:
Premium $:   # of Support Staff:
# of Lawyers who have attended CLE:
   


Attorney Names Designation Date Admitted to Bar House Worked Per Week


Other Information

 
Number of suits for fees filed in the past two years:  
Date firm established:  
 
Docket Type:  


                   
 
Is your docket maintained by at least two people?  
                  
How frequently is your docket cross-checked?  
                  
 
Conflict Type:  


                   
 
If a sole practitioner, do you have a back-up attorney?  
                  
Do you use Engagement Letters?  
                  
Fee Agreements?  
                  
Declination Letters?  
                  
 
Does any attorney in the firm serve as a director, officer, or
employee of any client of the firm?
 
                  
If yes, provide details:
 
 
Does any attorney hold an equity interest in any client's business?  
                  
If yes, provide details:
 
 
Has any member of the firm been disbarred, reprimanded,
suspended, had license revoked or had any complaint or
disciplinary action?
 
                  
If yes, provide details (Prior claim supplements with updates will be helpful):
 
 
Over the last five years, has any attorney of the firm
(past or present) had a malpractice claim filed against them
or reported an incident or circumstance to a
malpractice carrier?
 
                  
If yes, provide details of incident/claim:
 
 

Disclaimer: This form is for estimate purposes only. Coverage may be bound only upon submission and acceptance of a completed application.