Commercial Quote Request

Chad Ellis, Principal

3500 Brooktree Road
Suite 300
Wexford, PA 15090
ph 724.933.8077
fx 724.933.8089

Commercial Client Information:

Client Name:

Street Address:

Address (cont.):

City:

State:

Zip Code:

County:

Contact Person:

Phone:

Fax:

E-mail Address:

Website:

Answer the Following:

Total Number of Employees: Are there any union employees? Yes    No
Total Number of Business Autos:    
Renewal Date: mm/dd/yy Has the company been active for 5+ years? Yes   No

Check Type of Quote Requested:

Commercial Lines

Property Auto Work Comp. General Liability
Crime Umbrella E & O ERISA

Notes:


 
 
 

Web Design by proSource

Copyright 2009 Agora Group, Inc
3500 Brooktree Road, Suite 300, Wexford, PA 15090

Telephone: 724.933.8077