To: Jody A. Harris, ARM, RPLU
Arthur J. Gallagher & Co.
125 S. Wacker Drive, Ste. 500
Chicago, Illinois 60606
Telephone: (312) 803-7395
E-mail: firstname.lastname@example.org Fax #: 312-803-6383/Pages ___________________
Re: Broker’s Letter of Market Authorization
To Whom It May Concern:
This confirms effective immediately, we have appointed Arthur J. Gallagher & Co. as our exclusive insurance broker with respect to our entire Lawyers Professional Liability
Insurance Program in negotiations with all Lawyers Professional Liability Insurance Carriers. The appointment of Arthur J. Gallagher & Co. rescinds all previous appointments, and the authority contained herein shall remain in full force until canceled in writing.
(Name of Firm)
(Title of Officer)
TENNESSEE BAR ASSOCIATION
LAWYERS’ PROFESSIONAL RISK SERVICES
Premium Estimate Request
Completed application required for a firm quote
Fax back to: Fax No.: Firm: Contact: Street Address: City: State: Zip: County: Email: Website: Telephone: Fax:
Current Policy Expiration Date: 1. Please tell us about your firm’s current coverage or attach a copy of your current policy. A. Number of years of continuous coverage: E. Annual premium for how many attorneys? B. Current Professional Liability Carrier/Program: F. Deductible: C. Current Limits: G. Per Claim or Annual Aggregate: D. Retroactive Data (if any): H. Does your current policy modify or exclude coverage? 2. Please provide information about the attorneys in your firm. (Attach additional sheet if necessary)
4. Claims Information 3. If “of counsel” and part-time attorney provide number of hours worked on behalf of firm. Please tell us what percentage of billable hours not income you spend in the How many claims, including disciplinary matters, have following areas of practice: been made against your firm or any present or past partners, employees, or “of counsel” in the last five years? Admiralty/Marine International Law How many incidents, circumstances, errors, omissions or offenses, which may result in a claim being made against Anti-trust/Trade Labor Law/Management Union your firm, are you now aware? Bankruptcy Local Government If yes to any of the above, provide the date of each claims Financial Instit/Banking Natural Resources/Oil/Gas or incident, the carrier reported to status, total payments Business Transaction Patent made to date, insurer’s loss reserve, and the claimant’s Civil Litigation Personal Injury (Class Action) settlement demand or estimated case value. Prior claim supplements with updated information will be accepted. Civil Rights Personal Injury (Defense) Collection Personal Injury (Plaintiff) Construction Real Estate – Commercial Consumer Claims Real Estate – Residential 5. Does any attorney in your firm serve as a director, officer, or employee, or have Copyright/Trademark Securities/Bonds any equity interest, in any client of the firm? Yes No (if yes, please provide details on another sheet) Corporate/Business Syndication/Limited Partnership Does the firm have a docket system with two independent date controls? Criminal Taxation Yes No Entertainment Wills/Estates/Trusts Do you have a conflict of interest avoidance system? Yes No Environmental Law Workers’ Compensation – Defense Do you use engagement/disengagement letters Yes No Family Law Workers’ Compensation – Plaintiff How many suits for fees have you filed against your clients in the last two years? Government Contracts Other Have any of the firm’s attorneys been the subject of any disciplinary action, for any Immigration/Naturalization = Total (must equal 100%) reason other than nonpayment of dues, within the last five years? Yes No (If yes, please provide details on another sheet) Do you share office space with other firms? Yes No If yes, does the firm share letterhead? Yes No
Note: This form is for estimate purposes only. Completing this form is not a guarantee of underwriting acceptability or premium rate. Coverage may be bound only on submission and acceptance of a completed new business application.