Amity Insurance, an innovator in the insurance industry since 1978.

Contact Name*

Firm Name

Street Address

City

State*

Zip Code

Phone Number*

Fax

Email Address*

About Your Firm

Number of attorneys in your firm

Date firm was established

Number of attorneys participating in CLE courses this past year

Has any attorney been disbarred, suspended, reprimanded, sanctioned, or been the subject of a disciplinary complaint?
 Yes No

If yes, please forward details

Indicate length of service with your firm
---0 years1 year2 years3 years4 years5 years6 years7 years8+ years

Docket System

How many independent date controls are maintained?

How often are they cross-checked?

Internal Procedures

Do you have a conflict of interest procedure?
 Yes No

Is it in the firm's general practice to use client communication letters?
 Yes No

How many suits for fees have been filed in the past two years?

Does any attorney serve as director, officer, or employee of any client and/or have equity in any client?
 Yes No

Your Claim History

Have you ever reported any claims/incidents in the last ten years?
 Yes No

If yes, number of claims, dates, and amounts (if paid) reported:

Your Insurance History

Current insurance carrier

How long has your firm maintained continuous insurance?

Current expiration date

Current premium

Current limits and deductible

Your Practice
Indicate if the percentages will be expressed in time or gross receipts

% Admiralty

% Arbitration / Mediation

% Banking (legal counsel excluding real estate closings)

% Bankruptcy / Collections / Repossessions

% Civil Rights / Discrimination

% Corporate General

% Criminal Matters

% Defense: Personal Injury / Workers Compensation / Product Liability

% Corporation Formation

% ERISA / Employee Benefits Plan

% Entertainment / Sports / Celebrity

% Environmental

% Estate Planning

% Family Law / Domestic Relations

% Immigration / Naturalization

% Probate / Trust / Wills

% International Law

% Labor - Employee Relations

% Labor - Management Representation

% Litigation - General & Corporate

% Municipal Law - Other

% Patent / Copyright / Trademark

% Plaintiff - Personal Injury / Workers Compensation / Product Liability

% Public Utilities

% Real Estate / Residential

% Securities Law

% Taxation

% Other (provide details below)

Details

Note: Submitting form does not bind Amity Insurance, but indicates an interest in seeking information on estimated cost and coverage highlights