First Name:
Last Name :
Business Name :
Street Address:
City:
State:
Zip Code:
Phone Number:
Alternate Telephone:
Fax Number:
Email Address:
Referred By:
-Select Referred By-
Bob Arnold, VP
Joe Barrick,VP
Jack Collier
Ben Slingluff,Pres.
Kevin Payne
Steve Thompson,VP
Myron Williams,VP
Elaine Ethridge
Carman Strickland
Judy Lietzan
April Parker
Phyllis Peters
Kandy Groover
Beverly Higginbotham
Ann Johnson
Debbie Kirkland
Sandra Bullard
Sandra Woodham
Sheena Butts
Underwriting Information
What is the nature of your business?
Is the business a corporation, partnership, or sole proprietorship?
Number of owners
Number of Employees
Payroll of Owners
Payroll of Employees
Total annual gross receipts
Years of experience
Years operated under current name
Other business names
Please describe the nature of your business and ANY unusual exposures:
Payroll Detail Information Employee Group 1
Class / Code
Payroll Rate
Annual Payroll
Employee Group 2
Class / Code
Payroll Rate
Annual Payroll
Employee Group 3
Class / Code
Payroll Rate
Annual Payroll
Employee Group 4
Class / Code
Payroll Rate
Annual Payroll
Employee Group 5
Class / Code
Payroll Rate
Annual Payroll
Claims Information
Were there any losses or claims in the last 5 years?
If yes, what is the date, amount paid and description of each loss or claim?
Coverage Information
Current Insurance Company
How much are you paying now?
What is the liability limit requested?
-Select- 100,000 300,000 500,000 1,000,000 2,000,000
Questions or Comments
Best Time To Contact You Please let us know the best time to call and discuss your quote.
Or Specify Other:
