(This is not an application for insurance)

First and last name of the person submitting this application:


Address:


City: State: Zip:

Phone: Fax:

Your Email:

1) Please indicate details of paralegal services rendered with approximate percentage of fee income from each: (total should equal 100%)

% (a) Filing or recording documents in the county or similar offices.

% (b) Certifying of Court Records.

% (c) Notifying Lawyers of Court Records.

% (d) Title Abstracting.

% (e) Process servicing.

% (f) Lawyers Messenger.

% (g) Bankruptcy.

% (h) Collection/Repossession.

% (i) Court Reporting.

% (j) Probate / Trust Preparation of documents.

% (k) Probate / Trust Case Management.

% (l) Divorce Legal Document Preparation / Referrals.

% (m) Hearing Attendance.

(n) Please specify any other services:



2) What percentage of your time do you devote to free lance services?
(a) 0% - 9%
(b) 10% - 19%
(c) 20% - 29%
(d) 30% - 39%
(e) 40% - 49%
(f) 50% - 59%
(g) 60% - 69%
(h) 70% - 79%
(i) 80% - 89%
(j) 90% - 100%


3) Have any claims or claims circumstances ever been brought against you? YES NO

If answer is YES, was this a case where you provided free lance services? YES NO


4) Have you been or are you currently subject to sanction by your tribunal and/or disciplinary commission? YES NO


5) Do you currently have Professional Liability Insurance for your paralegal services? YES NO

Name of Current Carrier:



6) Do you need your Paralegal Professional Liability Insurance to extend to services provided to employer organizations/law firms that you service under contract? YES NO


7) Limits of Liability. Indicate limit that you desire, or are required to maintain:
(a) $100,000
(b) $250,000
(c) $500,000
(d) $1,000,000