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Firm Information
Lawyer Information
Prior Claims
Prior Insurance
Limits and Deductibles
Firm Information
Step 1 of 5
Full Legal Name of the Firm
*
Trade Name or D/B/A
Principal Street Address
*
City
*
State
*
--None--
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
NE
NH
NJ
NM
NV
NY
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WI
WV
WY
Zip Code
*
County
*
--None--
ADAMS
ALEXANDER
BOND
BOONE
BROWN
BUREAU
CALHOUN
CARROLL
CASS
CHAMPAIGN
CHRISTIAN
CLARK
CLAY
CLINTON
COLES
COOK
CRAWFORD
CUMBERLAND
DE KALB
DE WITT
DOUGLAS
DU PAGE
EDGAR
EDWARDS
EFFINGHAM
FAYETTE
Federal Court—IL
Federal Court—other state
FORD
FRANKLIN
FULTON
GALLATIN
GREENE
GRUNDY
HAMILTON
HANCOCK
HARDIN
HENDERSON
HENRY
IN 1
IN 2
IN 3
IN 4
IN 5
IROQUOIS
JACKSON
JASPER
JEFFERSON
JERSEY
JO DAVIESS
JOHNSON
KANE
KANKAKEE
KENDALL
KNOX
LA SALLE
LAKE
LAWRENCE
LEE
LIVINGSTON
LOGAN
MACON
MACOUPIN
MADISON
MARION
MARSHALL
MASON
MASSAC
MCDONOUGH
MCHENRY
MCLEAN
MENARD
MERCER
MONROE
MONTGOMERY
MORGAN
MOULTRIE
OGLE
OTHER
PEORIA
PERRY
PIATT
PIKE
POPE
PULASKI
PUTNAM
RANDOLPH
RICHLAND
ROCK ISLAND
SALINE
SANGAMON
SCHUYLER
SCOTT
SHELBY
ST. CLAIR
STARK
STEPHENSON
TAZEWELL
TO BE DETERMINED
UNION
VERMILION
WABASH
WARREN
WASHINGTON
WAYNE
WHITE
WHITESIDE
WILL
WILLIAMSON
WINNEBAGO
WOODFORD
Website
Firm Phone Number
Firm Fax Number
Contact First Name
*
Contact Last Name
*
Contact Phone Number
*
Contact E-mail Address
*
Would you like to receive a link to this application via email
Date Firm Established
[
4/25/2024
]
How did you hear about us?
*
--None--
Search Engine
Email
ISBA
Journal
Instagram post/story
Facebook post/group
Google Ads
Twitter post
Word of mouth
Other
Unknown
Please describe your general Areas of Practice
*
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Lawyer Information
Step 2 of 5
Number Of Lawyers To Insure
*
--Select--
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Add Additional Lawyer
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Prior Claims
Step 3 of 5
After inquiry, during the past five (5) years, has any professional liability Claim* been made against the Firm, any Predecessor Firm, any present Lawyers of the Firm, or to your knowledge, any former Lawyer with the Firm or Predecessor Firm?
Yes
No
After inquiry, is the Firm or any Lawyer in the Firm, aware of any potential Claim* including but not limited to an act, error, omission, fact, circumstance, a request for a tolling agreement, a request for a deposition, a subpoena request for any file, ARDC complaint, situation, legal work, or any allegation of negligence that might result in any professional liability Claim* against the Firm, or any Predecessor Firm, or any past or present Lawyer in the Firm regardless whether such Claim* would be without merit?
Yes
No
Have any of the Firm’s Lawyers been the subject of any disciplinary actions, investigations or proceeding by any court, bar association, administrative agency or regulatory body?
Yes
No
*Claim
means a demand received for money or services, or the service of a suit or the initiation of an arbitration proceeding against the Applicant Firm that seeks damages arising out of an act, error or omission in rendering professional legal services including an act, error or omission of which the Applicant Firm, or anyone associated with the Applicant Firm is aware and which they know, or ought reasonably to have known, might give rise to a demand for money or services, or the service of suit or arbitration proceeding against them.
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Prior Insurance
Step 4 of 5
Is the firm currently insured?
Yes
No
Unsure
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Limits and Deductibles
Step 5 of 5
Select limits of liabilty and deductible. The limits are shared by the Firm and all lawyers of the Firm.
Limits of Liability - Each Claim / Annual Aggregate
Unsure at this time
250,000 / 500,000
500,000 / 500,000
500,000 / 1,000,000
1,000,000 / 1,000,000
1,000,000 / 2,000,000
1,000,000 / 3,000,000
2,000,000 / 2,000,000
2,000,000 / 4,000,000
3,000,000 / 3,000,000
4,000,000 / 4,000,000
5,000,000 / 5,000,000
5,000,000 / 10,000,000
6,000,000 / 6,000,000
7,000,000 / 7,000,000
8,000,000 / 8,000,000
9,000,000 / 9,000,000
10,000,000 / 10,000,000
10,000,000 / 20,000,000
15,000,000 / 15,000,000
20,000,000 / 20,000,000
Deductible - Each Claim
Unsure at this time
0
1,000
2,000
2,500
3,000
4,000
5,000
6,000
7,000
8,000
9,000
10,000
15,000
20,000
25,000
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Submit
Your application has been submitted successfully and you will be contacted by an ISBA Mutual representative. This application reference number is
. If you have any questions, please reach out to us at
sales@isbamutual.com
or
(312) 379-2000
.
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to return to the ISBA Mutual website.
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