Interested in Applying for Lawyers’ Professional Liability Coverage?
We have two easy options to complete your premium indication form:
  1. In a hurry? Complete the short form on the right to immediately access our downloadable indication form.
  2. Have 10-15 minutes to spare? Complete the on-page form below.

Either way, once we receive the completed form we will contact you promptly regarding a lawyers’ professional liability premium indication for your law firm. We look forward to working with you!

Completion of this form does not constitute an insurance binder. The information provided on this form will be used to provide a non-binding premium indication. Any resulting premium indication does not obligate Hirsch Insurance Brokerage to bind coverage and/or issue an insurance policy. Final premium quotation will be subject to the completion of an insurance carrier application. Review of the application and subsequent binding approval by the insurance carrier are necessary.

1. General Firm Information

First
Last
Principle Business Address (No P.O. Boxes):
Street
City
County
State
Zip

2. Current Insurance Information

If YES, please complete the current insurance information.

3. Firm Management

Internal Procedures

4. Claims History

5. Attorney Information

List all attorneys, including yourself, to be insured. “Of Counsel” attorneys must be listed if coverage is desired. (More than five attorneys, please add in “Further Information”.
First
Last
Attorney #2
First
Last
Attorney #3
First
Last
Attorney #4
First
Last
Attorney #5
First
Last
Further Information

6. Areas of Practice

Areas of Practice based upon the income derived from each category.
Enter a number as a percentage . Total of all categories must equal 100%. Don't worry – it will be added up for you.

7. Optional Coverage Requested-Subject to Underwriting Review

We respect your privacy. Your information will be sent securely and handled with care.
View our privacy policy.

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