Application

Please take a moment to fill out the form below and one of our representatives will contact you with a free, no-obligation quote. This information will be kept confidential and will be used for quote purposes only.

* Please complete the below application in its entirety.

If binding coverage, it must be signed & dated by an authorized representative/officer of the Sponsoring Law Firm. Click to Print the Application (PDF).

Application

Your Name:

Officer Full Name:

Officer Title:

Law Firm’s Insurance Agency/Broker (if applicable):

Sponsoring Organization:

Sponsoring Organization Address:

City:

State:

Zip:

Phone:

Contact E-mail Address:

Defined Group:
(Partners Only? etc...)

Is Coverage Mandatory for All Members of the Defined Group? Yes No

Proposed Coverage Term:

Member Information: Number Total Potential Members in Group:

Provide Information Below for Quote:

State of Residence	Requested Limits ($1M - $10M)	Est.'d No. Members	No. Youthful Drivers ( < Age 21 )	No. of Secondary Residences






		Total:	Total:	Total:

UM/UIM coverage is available & capped @ $1,000,000 limit. Do you want us to quote rates with this additional coverage? Yes No

Provide the premium and incurred loss information for the Sponsoring Organization's group umbrella/excess coverage for the past 5 years.

To your knowledge, does any Member (including all drivers in member's household) have a major driving violation (i.e., DUI, Reckless Driving, etc.) or a license suspension in the past 3 years? Yes No

Is any member of your firm a regionally or nationally elected public official OR a nationally-known celebrity? Yes No

Schedule of Required Underlying Insurance
Exposure	Coverage	Minimum Required Underlying Limit

Automobile Liability (Owned, Leased or Rented)	Bodily Injury	$250,000 per person, $500,000 per occ.
	Property Damamge or	$50,000 per occ.
	Combined Single Limit	$500,000 per occ.

Personal Liability (Homeowners, Condo Owners, Tenants, CPL)	Combined Single Limit	$300,000 per occ.

UM/UIM (When coverage is provided by our policy)	Bodily Injury	$250,000 per person, $500,000 per occ.
	Property Damage or	$50,000 per occ.
	Combined Single Limit	$500,000 per occ.

Watercraft Liability	Combined Single Limit	$300,000 per occ. for watercraft under 26 ft. or under 50 HP
		$500,000 per occ for watercraft 26 ft or more or 50 HP or more

Recreational Vehicle Liability	Combined Single Limit	$300,000 per occ.

Employers Liability	Combined Single Limit	$100,000 per occ.

Additional Comments or Questions

	Please check to confirm that you currently have (and will maintain) the Required Underlying Insurance.

	By checking the box to the left, you verify that all of your representations on this application are true and accurate to the best of your knowledge.

Please click the "Submit Application" button to send your quote request. No coverage is in effect until bound by an insurance carrier. This is a request for quotation only.

Application

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