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- Al Hernandez
- Debbie Hernandez
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818-576-9205

Home
Company
Brokers
- Al Hernandez
- Debbie Hernandez
Insurance Services
Request A Quote
Contact Us

Home
Company
Brokers
- Al Hernandez
- Debbie Hernandez
Insurance Services
Request A Quote
Contact Us

818-576-9205

Home
Company
Brokers
- Al Hernandez
- Debbie Hernandez
Insurance Services
Request A Quote
Contact Us

Request A Quote

Home / Request A Quote

Premium Indication Form

Step 1 of 6

16%

1. Please start by telling us a little about your firm. (Step 1 of 6)

Firm Name

Date Established

MM slash DD slash YYYY

Principal Business Address

City

State

Zip

Contact Name

Contact Email

Phone

Fax

2. Attorney List - All attorneys must be listed to be considered as insureds. (Step 2 of 6)

Attorney List

Row ID	Attorney Name	States Admitted	D/C	Actions

There are no Attorneys.

Maximum number of attorneys reached.

If you are a solo practitioner, do you have a back up attorney?

Backup Attorney

No

Yes

N/A

3. Indicate the percentage of time devoted to each specialty during the previous year. Express percentages in whole numbers next to the TYPE OF LAW practiced, not the business of the client you represent. (Step 3 of 6)

Admiralty/Marine

Please enter a number from 0 to 100.

Anti-Trust Trade Regulation

Please enter a number from 0 to 100.

Arbitration/Mediation

Please enter a number from 0 to 100.

Banking*

Please enter a number from 0 to 100.

Bankruptcy

Please enter a number from 0 to 100.

Bodily Injury/Defense

Please enter a number from 0 to 100.

Bodily Injury/Plaintiff

Please enter a number from 0 to 100.

Collection Repossession

Please enter a number from 0 to 100.

Copyright/Patent/TM*

Please enter a number from 0 to 100.

Corporate

Please enter a number from 0 to 100.

Criminal

Please enter a number from 0 to 100.

Domestic Relations

Please enter a number from 0 to 100.

Entertainment

Please enter a number from 0 to 100.

Environmental

Please enter a number from 0 to 100.

ERISA

Please enter a number from 0 to 100.

Est. Plan/Probate/Trust/Wills

Please enter a number from 0 to 100.

Immigration

Please enter a number from 0 to 100.

International Law

Please enter a number from 0 to 100.

Investment Counseling

Please enter a number from 0 to 100.

Labor Relations

Please enter a number from 0 to 100.

Public Utilities

Please enter a number from 0 to 100.

Real Estate - Residential

Please enter a number from 0 to 100.

Real Estate - Commerical

Please enter a number from 0 to 100.

Real Estate - Synd. Devel.

Please enter a number from 0 to 100.

Real Estate - Title Work

Please enter a number from 0 to 100.

Real Estate - Condo Offering

Please enter a number from 0 to 100.

Securities - Federal*

Please enter a number from 0 to 100.

Securities - State*

Please enter a number from 0 to 100.

Securities - Private Placements*

Please enter a number from 0 to 100.

Securities - Bonds*

Please enter a number from 0 to 100.

Social Security / Disability

Please enter a number from 0 to 100.

Tax Preparations

Please enter a number from 0 to 100.

Tax Opinions

Please enter a number from 0 to 100.

Workers Comp/Defense

Please enter a number from 0 to 100.

Workers Comp/Plaintiff

Please enter a number from 0 to 100.

Other (describe if over 5%)

Please enter a number from 0 to 100.

If % in BI/PI Plaintiff is Med Mal, please provide the following:

Average Case Value

Max Value

Description of other services:

Description of Other

Does the firm perform class action services?

Class Action

No

Yes

Are class action services defense only?

Class Action Defense Only

No

Yes

Total from above (should equal 100%)

4. Please answer the following questions regarding the firm’s Business Procedures. (Step 4 of 6)

Total number of suits for the collection of legal fees in past 3 years:

Total number of support staff:

Does the firm maintain a planned docket and calendar control system and procedures?

Calendar Control

No

Yes

Is your planned docket and calendar control system electronic?

Electronic Calendar

No

Yes

Are two separate individuals entering dates into different calendars/systems for the same matter?

Two Calendars

No

Yes

Does the firm issue engagement, declination, disengagement/closing letters on a regular basis?

Closing Letters

No

Yes

Gross Billable Dollars for This Year

Date Ending

MM slash DD slash YYYY

Gross Billable Dollars for Last Year

5. Please answer the following questions regarding the firm’s Professional Liability Coverage. (Step 5 of 6)

Current Insurance Company

Current Limits

Current Deductible

Current Premium

Number of years the firm has had continuous professional liability coverage:

Continuous Coverage

Current Policy Effective Date

MM slash DD slash YYYY

Retroactive Date

MM slash DD slash YYYY

6. Please answer the last few questions and then hit SUBMIT to complete the form. (Step 6 of 6)

Has any insurer declined, canceled or non-renewed your professional liability policy?

Declined or Cancelled

No

Yes

Has any attorney in the firm been refused admission to practice, disbarred, suspended, reprimanded, sanctioned or have any disciplinary complaints or ongoing disciplinary investigations?

Refused Admission

No

Yes

During the past five years, has any professional liability claim, suit or potential claim been made against any past or present attorney of the firm or are you aware of any act, error or omission that can result or give rise to a claim, potential claim or incident?

Claim Agains

No

Yes

If you answered yes to any of the questions above in section 6, please provide a brief explanation:

Request a Call Back

Request a <strong>Call Back</strong>

Request a Call Back and our team will get in touch with you ASAP.

Contact Information

Lawyers Pacific Insurance Brokerage is a leader in providing lawyers professional liability insurance solutions for California lawyers.

Office Location

18017 Chatsworth St #550
Granada Hills, CA 91344
Email: info@lawyerspacific.com
Phone: 818-576-9205

Mon-Fri: 9AM-5PM

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