Main Office: 9400 Ridgeway Avenue, , IL 60203  Phone: 312-239-2811  Fax: 312-896-1513
Chicago Office: 626 W. Jackson Blvd, Suite 500, Chicago, IL 60661  Phone:312-239-2811  Fax: 312-896-1513
Web Site: www.RichmondInsurance.com  E-Mail: TRichmond@RichmondInsurance.com

PREMIUM INDICATION FORM
Please attach your most recently completed application material which will supplement the material below.

1.	     		     	
	NAME OF FIRM		YR. FIRM EST.	
	     		     	
	PHYSICAL ADDRESS		SIGNATURE	
	     	     		     			
	CITY		STATE		COUNTY			IS FIRM:	
	     		     			SOLE PRACTITIONER	
	BUSINESS PHONE	BUSINESS FAX		PARTNERSHIP	
	     	     			PROF. CORPORATION	
	CONTACT PERSON		EMAIL ADDRESS			OTHER            	

2.	PROVIDE INFORMATION ON ALL ATTORNEYS THAT RENDER SERVICES ON BEHALF OF THE FIRM	
		Principal	Ind. Cont.	States	Date	Date	Number	
		Associate		Licensed to	Admitted	Joined	of Hours	
	NAME OF ATTORNEY(S)	Of Counsel		Practice	To Bar	Firm	Worked	
				Month/Year	Month/Day/Year	Per Week	
	1.            	     	     	     	     	
	2.            	     	     	     	     	
	3.            	     	     	     	     	
	4.       	     	     	     	     	     	
	5.       	     	     	     	     	     	
	6.       	     	     	     	     	     	
	7.       	     	     	     	     	     	
	8.            	     	     	     	     	
	9.       	     	     	     	     	     	
	10.            	     	     	     	     	
	PROVIDE THE SAME INFORMATION ON ADDITIONAL ATTORNEYS BY ATTACHMENT	
3.	IS THE FIRM CURRENTLY INSURED:      IF YES, WHAT IS THE PRIOR ACTS EXCLUSION DATE, if any 	     
		          mm / dd / yy	
		
		Limits of	Deductible	Premium Paid	Expiration Date	
	Insurance Company	Liability	Amount		Month / day /year	
	          	     	     	     	
4.	Please select the limits and deductible desired:	

	Limits:  Per Claim / Policy Aggregate	Deductible	
		$100,000 / $300,000		$500,000 / $1,000,000		$2,500	
		$250,000 / $500,000		$1,000,000 / $1,000,000		$5,000	
		$500,000 / $500,000		$1,000,000 / $2,000,000		$10,000	
		Other please specify:	$      		Other please specify:	$     	

  5.	If you are a sole-practitioner, do you have a back-up attorney?	Error! Reference source not found. Yes    Error! Reference source not found. No	

6.	Number of support staff:	Paralegal / Law Clerk	     	Secretarial	     	Other	     	

7.	Is the firm’s date/docket control system computerized?	Error! Reference source not found. Yes    Error! Reference source not found. No	

8.	Does the firm have a conflict of interest avoidance system?	Error! Reference source not found. Yes    Error! Reference source not found. No	

9.	Indicate percentage of time the firm utilizes:		
	a)	An engagement letter/contract when accepting a new client?	     %		
	b)	A non-engagement letter when declining to represent?	     %		
	c)	A disengagement letter when concluding a matter?	     %		

10.	How many suits for collections of attorney’s fees have been filed by the firm in the last 24 months?	     	

11.	Has any attorney been the subject of a reprimand, disciplinary action or grievance in the 
past 5 years?  If yes, provide details by attachment.	Error! Reference source not found. Yes    Error! Reference source not found. No	

12.	Has any attorney ever had malpractice coverage cancelled or non-renewed?  
If yes, provide details by attachment.	Error! Reference source not found. Yes    Error! Reference source not found. No	

13.	Has the firm or any of its attorneys had a claim, suit or incident in the past 5 years?  
If yes, provide details by attachment.	Error! Reference source not found. Yes    Error! Reference source not found. No	

14.	Please indicate percentage of time your firm devotes to the following areas of practice:		

Admiralty / Marine - Defense	      %	Litigation	
Admiralty / Marine - Plaintiff	      %		Class Action – Defense	      %	
Anti-Trust / Trade Regulation	      %		Class Action – Plaintiff	      %	
Arbitrator / Mediator	      %		General Commercial – Defense	      %	
Appellate Law	      %		General Commercial – Plaintiff	      %	
Banking / Regulatory	      %		Insurance Defense	      %	
Bankruptcy	      %		Personal Injury/Prop Damage – Defense	      %	
Business Transactions/Corporate Law		Personal Injury/Prop Damage – Plaintiff	      %	
	Administrative	      %		Workers’ Compensation – Defense	      %	
	Formation of Entities	      %		Workers’ Compensation – Plaintiff	      %	
	General Contract Negotiation	      %				
	Mergers & Acquisitions	      %	Local Government/Municipal (not bonds)	      %	
			Natural Resources/Oil & Gas	      %	
Civil Rights / Discrimination	      %	Public Utilities	      %	
Collections	      %	Real Estate	
Construction (Building Contracts)	      %		Real Estate - Commercial	      %	
Consumer Claims	      %		Real Estate - Development	      %	
Criminal	      %		Real Estate - Foreclosure	      %	
Entertainment	      %		Real Estate - Residential	      %	
Environmental Law	      %		Real Estate - Title Work	      %	
ERISA/Pension/Employee Benefits	      %		Real Estate - Syndication	      %	
Family Law				
	Adoption		School Law	      %	
	Divorce – marital assets < $500,000	      %	Securities (SEC, Blue Sky, Bonds)	      %	
	Divorce – marital assets > $500,000	      %	Taxation	
	Elder Law	      %		Business	      %	
	Guardianship/Juvenile	      %		Individual	      %	
	Social Security	      %		Tax Litigation	      %	
Govt. Contracts/Claims	      %		Opinions	      %	
Healthcare – Regulatory Compliance	      %	Wills, Estate, Trust, Probate & Planning	
Immigration/Naturalization	      %		For assets < $500,000	      %	
Intellectual Property	      %		For assets > $500,000	      %	
International Law	      %	Other (please describe):     		
Labor/Employment – Management	      %	     	      %	
Labor/Employment – Employee or Union	      %	Total	100 %	

PLAINTIFF PRACTICE SUPPLEMENTAL QUESTIONS

Please complete these questions if your firm handles any personal injury, automobile Accident, slip/fall, class-action, medical malpractice, product liability plaintiff cases.  If you have completed a Supplement like this one for another carrier within the last year, please simply send us that material in lieu of answering the questions below.

1.	Have you advertised during the past 12 months through any of the following:
	Television					  Yes		  No
	Radio						  Yes		  No
	Newspaper					  Yes		  No
	Yellow Pages					  Yes		  No

2.	Total number of personal injury cases your firm has handled during the past 12 months:  		     
3.	Average number of personal injury cases each attorney at your firm handles per year		     
4.	Percentage of your plaintiff cases that are:
		Settled before trial?      %		Cases tried to conclusion?       %
		Referred to you by other law firms?      %

5.	Do you use written referral agreements in all cases which are referred to you?	  Yes		  No
6.	Do you use written referral agreements in all cases which are referred out by you?  Yes		  No
7.	Do you obtain certificates of insurance in all cases which are referred out?	  Yes		  No
8.	Do you use Settlement Authority Agreement forms (signed by your client) when settlements are reached?
									  Yes		  No
9.	Average dollar value of your firm’s plaintiff cases:
	Less than $25,000		 $25,000 – $100,000		 $100,001 - $500,000
	 $500,001 - $1,000,000		 Other      
10.	What percentage of your plaintiff cases are:
	     % Class Action Suit		     % Legal Malpractice		     %Automobile Accident
	     % Medical Malpractice	     %Product Liability		     % Slip and Fall
	     % Other      
11.	With respect to your answer in question 10, please state the maximum dollar value of any one case:
	$      Class Action Suit			$     Legal Malpractice		$     Automobile Accident
	$     Medical Malpractice		$     Product Liability		$     Slip and Fall
	$     Other _____________________
12.	Percentage of recovery your firm takes as fee:			     
13.	Please attach a description of any class action litigation the firm has handled in the last three (3) years.  

ESTATE/TRUST SUPPLEMENTAL QUESTIONS

Complete these questions only if a percentage of practice was listed in question #15 in the Wills, Estate, Trust, Probate & Planning section of the Estimate Form.  If you have completed a Supplement like this one for another carrier within the year or two, please simply send us that material.

1.	List the Top Three largest Estates/Trusts to which the firm provided legal services in the previous 12 months:   

	Name					Attorney				Approximate Value
1.		     				     				     
2.		     				     				     
3.		     				     				     

	a.	What services are provided for the clients?
	______________________________________________________________________________________________________________________________________________________________________________________________________________________
b.	Does work performed include business formation, management, or other business transactions?								 Yes	   No

2.	Does any one Estate/Trust client account for 10% of an attorney’s annual billings?   Yes   No  If yes, percent of revenue:________

3.	Does your estate practice include a file review by a second attorney not involved in drafting on all new wills?										 Yes	   No

4.	Does any attorney currently serve as Executor/Personal Representative of an estate or Trustee of a trust (not including family related matters)?					 Yes	   No 

	If yes, provide a list by attorney with:   Name of Estate/Trust, approximate value, description of services provided.