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Novato Professional Liability Premium Form
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Novato Professional Liability Premium Form
Novato Professional Liability Premium Indication 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
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