Law Firm Name:

Address 1:

Address 2:

City:

County:

State:

Zip:

Telephone 1:

Telephone 2:

Fax:

E-Mail Address (if any):

Website Address (if any):

Firm's Members Name(s):

Firm's Practice Area(s) Expertise:

Automobile Insurance
Business Insurance
Computer/Intellectual Property Insurance
Disability Insurance
Environmental Insurance
Fire Insurance
Health Insurance
Home Insurance
Life Insurance
Personal Injury & Accident Insurance
Professional Malpractice
Property & Casualty Insurance
Theft Insurance
Wrongful Death

Other: 

Areas of Experience with Unfair Insurance Claims Practices and Class Actions if any):

Will you provide FBIC (and its member participants) a free Initial Consultation, as may be required:

 Yes   No

(If yes, according to the following restrictions if applicable):

Telephone

 Only    As Available

Other (explain)  

Firm's FBIC Contact Attorney 1:
First Name
M.I.
Last Name

Firm's FBIC Contact Attorney 2:
First Name
M.I.
Last Name

Firm's FBIC Contact Attorney 3:
First Name
M.I.
Last Name

Firm's FBIC Non-Attorney Contact :
First Name
M.I.
Last Name