Business

PHONE: (856) 881-6930

FAX: (856) 881-5577

General Information:

Name of Business:
Contact Name:
E-mail:
Street Address:
City:
State:
Zip:
County:
Business Phone:
Fax:
Best time to call:	AM PM

Current Insurance Company (not agency):

Company Name:
Policy Exp. Date:
What type of coverages do you currently have:	Bond Commercial Auto Commercial Liability Commercial Property Commercial Umbrella Directors & Officers Liability Disability Group Health Group Life Professional Liability Workers' Compensation Other

Business Information

# of full-time employees
# of part-time employees
How long in business	yrs.
How many locations
Annual Sales	$
Please give a brief description of your business and clientele
Any losses in the past 5 years	Yes No Date of loss
If yes, please explain

Please select the type of coverages you want:

Bond
Commercial Auto
Commercial Liability
Commercial Property
Commercial Umbrella
Directors & Officers Liability
Disability
Group Health
Group Life
Professional Liability
Workers' Compensation
Other

Additional Comments:

Please give any additional comments about the coverage you desire:

YourLocalCounty.com

29 S. Delsea Drive Glassboro, NJ 08028

PHONE: (856) 881-6930 FAX: (856) 881-5577

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