Novato Professional Liability Premium Form

Contact Information

Firm

City

Email

Phone

Provide the number of attorneys and their years of experience with the firm:

5+ years

# of full time attorneys

# part time (less than 25 hours)

4 years

# of full time attorneys

# part time (less than 25 hours)

3 years

# of full time attorneys

# part time (less than 25 hours)

2 years

# of full time attorneys

# part time (less than 25 hours)

1 year

# of full time attorneys

# part time (less than 25 hours)

Under 1 year

# of full time attorneys

# part time (less than 25 hours)

Current Coverage

Current Carrier

Retroactive Date (if any)

Number of years of continuous coverage

Current Policy Expiration Date

Current Limits

Deductible

Annual Premium

What percentage of Billable Hours (not income) do you spend in the following areas of practice?

% Admiralty/Marine

% Intellectual Property (Patent/Copyright/Trademark)

% Banking/ Financial Institutions

% Labor Law

% Business Transaction/ Commercial Law

% Local Government

% Civil Litigation/ Plaintiff (not personal injury)

% Natural Resources/ Oil & Gas

% Civil Litigation/ Defense

% Immigration/ Naturalization

% Civil Rights/ Discrimination

% Personal Injury/ Property Damage – Plaintiff

% Collection & Bankruptcy

% Personal Injury/ Property Damage– Defense

% Construction (Building Contracts)

% Real Estate/ Title– Commercial

% Consumer Claims

% Real Estate/Commercial– Residential

Real Estate/Commercial– Residential

% Securities (S.E.C)

% Criminal

% Taxation

% Environmental

% Wills, Estate, Trust & Probate

% Family Law

% Workers Comp. - Defense

% Government Contracts/ Claims

% Workers Comp. - Plaintiff

% Other

Other: Please describe

Error: the percentages above must add up to 100%

% Total

%

Past Actions

Have you had or reported any Professional Liability claims or incidents in the last five years?

Yes

No

Has the firm been involved in any mass tort or class action matters within the past five years?

Yes

No

Have any of the firm’s attorneys been subject of any disciplinary proceedings, for any reason other than nonpayment of dues, within the last 5 years?

Yes

No

Signature

Clear