This data is required to establish a permanent file on your firm. The primary purpose is to develop listing copy that will also enable us to answer inquiries received from legal/claims departments of insurance companies and/or self-insurers who may request more detailed information.

A complete street address and zip code must be listed. A P.O. Box may be included for mailing purposes.
 
Firm Name
Contact Name  
Building Address  
Street Address  
  County  
City State Zip  
  Telephone
 E-Mail
 
  Fax Number
Website
 
Mailing Address

P.O.Box City State Zip
Classification of Firm's insurance practice  
Please advise % of your firm's:
(A)- Defense Practice (C)- Plaintiff Practice
(B)- Subrogation Practice (D)- Other
Do you handle adjustments and investigations for insurance companies?
Total Number of firm members:
  Partners Associates of Counsel
Important: Please list contact names and addresses of insurance company and/or self-insured clients below

 

 One listing only per company
INSURANCE COMPANY & SELF-INSURED CLIENTS
(No banks or mortgage companies)		 NAME & COMPLETE ADDRESS OF INDIVIDUAL, BRANCH OFFICE, OR DEPARTMENT WHERE VERIFICATION LETTERS MAY BE SENT NO. OF YEARS REP.

Contact Name
Fax Number
Mailing Address
City, State,
Zip
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