To apply for membership on our panel, please fill out and then print this attorney/firm profile and return it to us with a copy of your malpractice insurance declaration page. You may fax it to us at 216-694-4328.




PARTICIPATING LAW FIRM PROFILE

Firm Name: 
Telephone:  -   -     Fax:  -   - E-mail: 
Address: 
     Street: 
     City:     County: 
     State:     Zip: 

     Mailing: City: 
     State:     Zip: 

Tax ID # (EIN or SS #) Is this for the Firm or Individual

Office appointments available: Normal business hours Saturdays Evenings
Do you have additional offices?  YesNo    **Attach letterhead or a separate list. ** 

Number of attorneys in firm: Avg. year's experience   Number of Support Staff 

Areas in which you generally accept clients: 

ALL GENERAL PRACTICE AREAS YESNO
FAMILY (Adoption, Divorce, Guardianship, Post Decree) YESNO
FINANCIAL (Bankruptcy, Debt Collection Defense) YESNO
REAL ESTATE (Purchase/Sale, Tenant Defense, Title Disputes) YESNO
LITIGATION (Civil Litigation, Consumer, Personal Injury) YESNO
CRIMINAL (Misdemeanors, Felonies, Juvenile, Expungement) YESNO
TRAFFIC (DUIS, Traffic Tickets, Driving Privileges) YESNO
PROBATE (Wills, Probate, Trusts) YESNO
ESTATE PLANNING  YESNO
ELDER LAW YESNO
IMMIGRATION YESNO
TAX LAW YESNO
SPECIAL NEEDS TRUSTS YESNO
OTHER SPECIALIZED AREAS 

Are you fluent in any foreign languages? YesNo     Language(s)
Type of business? Sole Practice Partnership Professional Assoc. Other
Do you have a current policy of malpractice insurance?YesNo       Expiration date (mo/yr): /

** A COPY OF THE DECLARATION PAGE SHOWING CURRENT COVERAGE MUST BE ATTACHED. ** 
 
 

 

EEO INFORMATION -  # of Attorneys: Male         Female 
African American          
American Indian or Alaskan Native          
Asian or Pacific Islander          
Caucasian          
Hispanic          
Other          

Individual Profile for Contact Attorney. NOTE: Any Attorney in the firm may provide services. 
Contact Attorney Name
Law School      Graduation Date  (mo/yr): / 
Admitted to practice: State Year State  Year

Has anyone in the firm ever received a reprimand, censure, suspension or other discipline from any 
Bar Association or Court? YesNo  If yes, please attach an explanation. 

Have you previously been a member of our panel?    YesNo     If yes, when  (mo/yr): / 
Please list any other legal plans from which you accept clients:
                           

Signature of responsible attorney:                                                                      

Please print the completed form and return it to us with a copy of your malpractice insurance declaration page to:
Panel Representatives - Recruiting, Hyatt Legal Plans, Inc., 1111 Superior Avenue, Cleveland, Ohio 44114-2507 or FAX it to: 216-694-4328.