Name of Applicant: DBA:
Address: City: State: Zip:
Email Address: Phone:

Type Of Business:
Annual Revenue prior Fiscal Year: Number of Employees:
Annual Revenue current Fiscal Year: Employee total payroll:
Annual Revenue projected next Year: Estimated number of records:
Firm's Established Date:
What is the firm's main concen in the event of a breach?

**For legal professionals only, please provide the total combined percentage of revenues derived from the following services:
1) Tax: 3) Medical Malpractice: 5) Intellectual Property:
2) Personal Injury: 4) SEC:

5. I would also like a quote for:

Errors and Omissions Coverage for Professional Services Rendered
Property Damage or Bodily Injury Claims
Discrimination, Sexual Harassment, Wrongful Termination, Retaliation and More
Employee Theft, Employee Theft of Client Property, Forgery or Alteration, Robbery and Sale Burglary, Computer and Funds Transfer Fraud and More
Employees' Medical and Disability Expenses Related to on the Job Injuries



This Form Is For Estimate Purposes Only.
Coverage May be Bound Only Upon Submission and Acceptance of a Completed Application.
Gilsbar Specialty Insurance Services, LLC
P. O. Box 998, Covington, Louisiana 70434