Complete Quick Quote application for Professional Liability coverage in less than 5 minutes!

Gilsbar, Inc. is the exclusive administrator for the CNA Lawyers Professional Liability Program in Alabama, Florida, Georgia, Louisiana, and Mississippi. To receive a Quick Quote for Professional Liability coverage, complete the form below and click SUBMIT. You will receive a email confirming that your quote request has been received. A Gilsbar representative will contact you with your premium indication. If you prefer to provide this information by phone, call us at 1-800-906-9654 or contact us by email.

Items marked with * are required.

Firm Contact Information
*Firm Name:
*Address:
*City:
*State:	Alabama Florida Georgia Louisiana Mississippi
*Zip:
*Year Established:
*Number of Attorneys:
*Number of Support Staff:
*Contact Person:
*Telephone Number:
*Email:
Percentage of Time Devoted (billable hours) in the following Areas of Practice during the previous year:
Part I - Specific Practice Areas % Admiralty/Marine - Defense % Immigration/Naturalization % Admiralty/Marine - Plaintiff % ** Intellectual Property - Copyright/Trademark % Anti-Trust/Trade Regulation % ** Intellectual Property - Patent % Banking/Financial Institutions % International Law % Business Transactions/Comm. Law % Labor Management Representation % Civil Rights/Discrimination % Labor Union Representation % Collection & Bankruptcy % Natural Resources/Oil & Gas % Construction (Bldg. Contracts) % Real Estate/Title - Commercial % Consumer Claims % Real Estate/Title - Residential % Corporate Business Organization % ** Securities (SEC) % Criminal % Taxation % Environmental % Wills, Estates, Trust & Probate % Family Law % Workers' Compensation – Defense % Government Contracts/Claims (Excluding Local Government) % ** Workers' Compensation – Plaintiff
Part II – Practice Areas Which Did Not Fall Into Part I % Civil Litigation Defense (excludingPersonal Injury /Property Damagecovered above) % ** Civil Litigation Plaintiff (excludingPersonal Injury / Property Damagecovered above) % Personal Injury / Property Damage – Defense % ** Personal Injury / Property Damage - Plaintiff % Other (please describe)
Total % (Must equal 100%)
** If any percentage, you may be asked to provide additional information once this request has been submitted.
Attorneys Working for the Firm
*List of Attorneys by Name Date Began Private Practice Hire Date Individual Prior Acts Date Relation to Firm (Use Codes*) Number of Hours Working for Firm [OC/IC] *Codes: [OF]Officer, [OC]of Counsel, [P]Partner, [SP]Solo Practitioner, [E]Employed Attorney, [IC]Independent Contractor
Additional Coverage Information
*Does the firm currently have coverage?:	YesNo
*Name of Current Carrier:
*Expiration Date:
*Retro Active Date:
*Present Liability Limit:
*Present Deductible:
*Premium:
*Has any attorney with the firm ever been disciplined or denied the right to practice within the past 5 years?:	YesNo
*Does your firm handle any Class Action and/or Mass Tort cases?:	YesNo
Number of Claims/Suits/Incidents Filed Against Firm in Past 5 Years
*Number Filed:
*Number Pending:
*Amount Paid:
*Amount Reserved
Referral Source
*How did you find out about Gilsbar’s Quick Quote Form?	Choose from below Bar Journal Bar Directory Internet Web Search ALA Event CLE Event Bar Convention Referred by Current Client State Bar WebSite Sales Person Received Letter/Mailing Referred by CNA I'm a Former Customer Bar Association Referred by other Carrier Received Email from Gilsbar Google Advertisement Other If other, please specify:
*Are you interested in receiving a quote for Title Professional's E&O Insurance?	YesNo
NOTE: This form provides information to process verbal indications only. All quotes are subject to completion of full application and underwriting approval. CNA is a service mark and trade name registered with the US Patent and Trademark Office. The program referenced herein is underwritten by one or more of the CNA companies.
Online Fax Consent By retyping my full name in the box below, I indicate that this is my signature and that I consent to receive faxes sent by or on behalf of Gilsbar, Inc. and its subsidiaries.
Fax Number:
Signature (type full name):
I acknowledge the above to be my electronic signature.
Today's Date: