Lawyers First Insurance - Broker for California Attorneys


	ASK US ABOUT SPECIAL RATES FOR THESE AREAS OF PRACTICE: Intellectual Property Immigration Criminal Defense Insurance Defense Call or fill out our indication form
	CONTACT US _________________ Margo Milman Tel: 310.689.5325 Fax: 310.235.0417 Email us at: margo_milman@ grosslight.com _______________________ Chelsea Lauber Tel: 310.689.5344 Fax: 310.235.0466 Email us at: chelsea_lauber@grosslight .com CA License# OC70777

Lawfirm

Firstname*	Lastname*

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 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, Trademark, 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?

6. 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?

Yes
No

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?

Yes
No

8. Do you currently have a professional liability broker?

Yes
No

Whether you’re a sole practitioner, independent contractor, or law firm in California, whether you are
a full-time, part-time attorney or just moonlight, we have the right lawyers’ professional liability insurance plan for you.