Gilsbar - Association Quote Request

If you would like to receive a quote for the LSBA or LCPA Members Insurance Programs, complete the form below. Various coverage options are available to members, employees and dependents. Upon submission, a sales representative will contact you within one (1) business day.

If you are looking for attorney's professional liability insurance only, click here.

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*How did you hear about us?:	I'm a current client I received an email I received a mailer Convention, seminar or event I'm a former client A sales person contacted me Advertisement I know the Gilsbar name Referral
If "referral" selected above, who were you referred by?:
*Full Name:
*Member's firm name or employer:

*Address:
*City:
*State:
*Zip:
*Email:
*Phone:	() -Second partThird part
*Association:
*Date of Birth:
Medical Coverage
Medical Coverage Type:
Medical Coverage Requested:
Spouse Date of Birth (if requested):
Long Term Disability
LTD Monthly Benefit Requested:
*maximum benefit: $7,500 or up to 70% of gross income
Term Life
Term Life Benefit Requested:
Term Life Benefit Requested for Spouse:
Spouse Date of Birth (if requested):
Term Life - Number of children you want to cover:
Other:
Attorney's Business Overhead Expense
Business Overhead Expense Monthly Benefit Requested:
Attorney's Professional Liability
Request Application for Professional Liability Coverage?:
Comments: