Insurance Specialists, Inc.
Has Been Providing
Professional Liability Insurance
Since 1965
Lawyers Professional Liability Insurance Premium Estimate
Applicant Firm Information
Firm Name
Contact Person
# of Attorneys in Firm
Phone Number
Fax Number
E-mail Address
Street Address (City, State, Zip Code, County)
Practice Survey Indicate the percentage of firm income derived from each area of practice.
1. Area of Practice
% of Firm Income
4. Area of Practice
% of Firm Income
2. Area of Practice
% of Firm Income
5. Area of Practice
% of Firm Income
3. Area of Practice
% of Firm Income
6. Area of Practice
% of Firm Income
To receive RaPid Rate premium estimate,
please complete and return this request to:
Insurance Specialists, Inc. - Professional Liability Dept.
12 Lenox Pointe
Atlanta, GA 30324
Phone: (888) ISI-1959 • Fax: (866) 871-2170
E-mail: [email protected]
Please attach a copy of firm letterhead and a copy of policy declarations
page (if available). Coverage may be bound only upon submission and
acceptance of a fully completed application.
Agent
Date of Completion