Attorney Prequalification Form

If you prefer to fax or mail your application, please download the PDF version.

Firm and Contact Information

* First Name

Middle Initial * Last Name

* Firm Name
* Physical Address Line 1
Physical Address Line 2
* City	* State * Zip
* Email:
*Telephone Number:	- - extension:
* Date Firm Established:
* Number of practicing attorneys
* Number of attorneys working less than 1000 hours/year

Please tell us about your Areas of Practice:

Percentage of Gross Billable Hours (Not Income) Derived from the Following Areas of Practice

If you are a new firm, please estimate the areas of practice that you anticipate your gross billings will be derived from in the upcoming year.

Percentage	Area of Practice
%
%
%
%
%	Other (if more than 5%, describe below)

Please tell us about your current coverage

* Do you have Professional Liability coverage through your current firm? Yes No

Claims History

* In the past five (5) years, has any Professional Liability claim or suit been against the firm or its predecessor firm(s) or any current or former member of the firm or its predecessor firm(s)?

* Total Number of Claims:

Additional Comments or Questions:

How did you hear about us?

Disclaimer

* I authorize BC to use info to research quote on my behalf
* Signature
* Signature acknowledgement
* Today's Date	mm/dd/yyyy