independent insurance group - business quote << return to previous page   North Carolina, South Carolina, Georgia and Virginia Businesses Only! Let us work with you to develop cost effective solutions to your business insurance needs. In most cases a personal interview will be required to properly quote business insurance. To help us better understand your business and its needs, you may fill out the form below or give us a call. Contact Information... Name (required) Address Address (second line) City State Zip Please Contact Me Via... Phone E-Mail Fax Work Phone Best Time To Call Select 8am-10am 10am-Noon Noon-1pm 1pm-3pm 3pm-5pm 5pm-7pm 7pm-9pm Home Phone Best Time To Call Select 8am-10am 10am-Noon Noon-1pm 1pm-3pm 3pm-5pm 5pm-7pm 7pm-9pm Fax E-Mail (required) Current Insurance Information... Current Insurance Company (not agency) Date Current Policy Expires mm/dd/yyyy Current Insurance Information Company Name (not agent or broker) Policy Expiration Date / / mm / dd / yyyy What type of coverages do you currently have? Bond Commercial Auto Property and Liability Workers Compensation Directors & Officers Liability Group Life & Health Professional Liability Other (please describe) About Your Business Number of full-time employees Number of part-time employees Years in business Number of locations Annual sales $     Provide a brief description of your business and customers. Select the type of coverages you want: Bond Commercial Auto Property and Liability Workers Compensation Directors & Officers Liability Group Life & Health Professional Liability Other (please describe)   Additional Comments or Questions This is a Request For Quotation Only. No coverage is in effect until bound by an insurance carrier.   Click once - wait a few seconds Thank You!

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