Quick Premium Indication | Florida Lawyers Mutual Insurance Company

Firm Information

Firm Name*

Contact Name*

Firm Address (Street Name & Number)*

Example, "123 Lawyer Rd."

City*

State*

Zip Code*

Phone Number*

Email Address*

This field is hidden when viewing the form

Info Break

Attorneys and Employees

Repeater

Lawyer Name*

First Last

Florida Bar Number*

Number of Years With the Firm*

Board Certified?*

Yes

Add LawyerRemove Lawyer

Number of Non-Lawyer Employees on the Firm*

This field is hidden when viewing the form

Practice/Attorney break

Current Policy Information

Currently Insured*

Yes

If Yes, what is the Effective Date*

If Yes, what is the Retroactive Date*

Own a Title Company?*

Yes

Limits of Liability per Claim/Total Limit*

$100,000/$300,000

$250,000/$500,000

$500,000/$1,000,000

$1,000,000/$1,000,000

Other

Other Claim

Deductible*

$2,500

$5,000

$10,000

Practice Information

Top Three Counties in Which 30% or More of Your Practice Is Based

1. County Name*

1. Percentage*

2. County Name*

Please enter only counties where you perform 30% or more of your work. For counties where you work less than 30%, please enter “NA” in County Name field and enter “0” in the Percentage field.

2. Percentage*

3. County Name*

Please enter only counties where you perform 30% or more of your work. For counties where you work less than 30%, please enter “NA” in County Name field and enter “0” in the Percentage field.

3. Percentage*

Percentage of Practice Out of State*

If practice out of state is not applicable, type "0" in this field.

Three Major Areas of Practice and Percentages

1. Area of Practice*

1. Percentage*

2. Area of Practice*

Total areas of practice must equal 100%. If additional areas of practice are not applicable, select "NA" in Area of Practice field and select "0" in Percentage field.

2. Percentage*

3. Area of Practice*

Total areas of practice must equal 100%. If additional areas of practice are not applicable, select "NA" in Area of Practice field and select "0" in Percentage field.

3. Percentage*

This field is hidden when viewing the form

Practice Info Break

Claims/Discipline Information

Number of Reported Incidents and/or Claims in Last 5 Years*

Number of Disciplinary Proceedings Before Any Bar within the Past 5 Years*

This field is hidden when viewing the form

Claims/Discipline Information Break

CAPTCHA