Name of Business

Contact Name

E-mail address

Address

City

State

Zip Code

County

Business Phone

FAX:

Best time to reach you

Current Insurance Company

(not agency)

Company Name

Policy Expiration Date

What type of coverages do you currently have?

 Bond
 Commercial Auto
 Commercial Liability
 Commercial Property
 Commercial Umbrella
 Directors & Officers

 Disability
 Group Health
 Group Life
 Professional Liability
 Worker’s Compensation
 Other

Business Information

Number of full-time employees

Number of part-time employees

How long in business?

 years

How many locations

Annual Sales

Brief description of your business and clientele

Please select the type of coverages you want

 Bond
 Commercial Auto
 Commercial Liability
 Commercial Property
 Commercial Umbrella
 Directors & Officers

 Disability
 Group Health
 Group Life
 Professional Liability
 Worker’s Compensation
 Other

Additional Comments

Please give any additional comments about the coverage you desire