Complete the form below and submit it online or, if you prefer, download the pdf  (  CNA Quick Quote Form  ), or  call us at (800)  556-0800.

CNA Quick Quote Form

• Firm:*
• Contact Person:
  First: Last:
• Address (optional)
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• Email
• List each attorney (click + to add up to 35)

  Attorney Name	Years in Private Practice	Years of Continuous Coverage

• List each area of practice for the firm and the % of time (click + to add additional areas of practice)

  % of Time	Area of Practice

• Year firm was established
• Retroactive date (if any) on your current policy
  MM slash DD slash YYYY
• Current professional liability carrier
• Current policy expiration date
  MM slash DD slash YYYY
• Current limits
• Current deductible
• Current annual premium
• Desired limits and deductible if different
• Have you reported any professional liability claims or incidents in the last five years?
  • Yes
  • No
• If yes, please provide the date the claim was reported, the status or disposition and the total amount paid in defense and indemnity.
• In the past two years, has the firm sued a client for fees?
  • Yes
  • No
• If yes, how many fee suits have been filed?
• Have any of the firm's attorneys been the subject of any disciplinary proceeding within the last five years?
  • Yes
  • No
• If yes, what discipline was imposed, if any?
• Does the firm handle any Class Action or Mass Tort cases?
  • Yes
  • No
• Untitled