Indication & Contact Request Form

Please complete for a no-obligation indication or to request more information:

***January 1, 2010 Rule 3-410 Disclosure of Professional Liability Insurance becomes effective as part of the California Rules of Professional Conduct. See our "Why You Need Insurance Page" for more details.***

Lawfirm
First name* Last name*
Address*

City* State* Zip / Postal Code*
Phone* Fax
Email* Website Address
 
1. Please provide the number of full time attorneys within your
firm, & their years of experience:

Yrs w/this Firm

# of Full Time Attorneys # of Part Time Attorneys
5+  
4
3
2
1
 
2. Please tell us what percentage of Billable Hours - not income -
you spend in the following areas of practice
(please express in whole numbers):

% of Time

Areas of Practice
Admirality / Marine
% Banking / Financial Institutions
% Business Transaction / Commercial Law
% Civil Litigation / Plaintiff (not personal injury)
% Civil Litigation / Defense
% Civil Rights / Discrimination
% Collection & Bankruptcy
% Construction (Building Contracts)
% Consumer Claims
% Coporate Business Organization
% Criminal
% Environmental Law
% Family Law
% Governmental Contracts / Claims
% Immigration / Naturalization
% Intellectual Property - Patent
% Intellectual Property - Trademark
% Intellectual Property - Copyright
% Labor Law
% Local Government
% Natural Resources / Oil & Gas
% Other:  
% Personal Injury / Property Damage - Plaintiff
% Personal Injury / Property Damage - Defense
% Real Estate / Title - Commercial
% Real Estate / Title - Residential
% Securities (SEC)
% Taxation
% Wills, Estate, Probate & Planning
% Workers Compensation - Defense
% Workers Compensation - Plaintiff
100%
 
3. Please tell us about your current coverage:
Number of years of continuous coverage:
Retroactive Date (if any) :
Current Professional Liability Carrier / Program:
Current Policy Expiration Date:
Annual Premium:
Current Limits:
Deductible:
4. Have you had or reported any Professional Liability claims
or incidents in the last ten (10) years?
*Please provide a detailed explanation, including payments & expenses

5. In the past five (5) years, has the firm sued a client for fees?





7. Have any of the firm's attorneys been the subject of any disciplinary proceedings, for any reason other than non-payment of dues, within the last five (5) years?



 
An answer of "yes" to question 4, 5, 6 or 7 may affect our ability to provide a rate indication as further information will be necessary.
 
8. Do you currently have a professional liability broker?



 
9. How did you find us?







 
This form is not an application for insurance. This form provides us with a profile of your firm so that we may better ascertain what carriers would be appropriate and what type of rate may be available upon a carrier's receipt, review and acceptance of a completed application.