The Atlanta Lawyer October/November 2015 | Page 9

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