The Yarmouth
Insurance Agency
"Your Personal Insurance
Agency"
General
Information
Your
Name
Last: First:
Business
Name
Street
Address1:
Street
Address2:
City:
State:
Zip:
Daytime
Phone:
(
)
Fax: (
)
Evening
Phone:
(
)
Best
Time To Call:
Email
Address:
Business Information
Business
Type:
Number
years in business
Did you operate
under any other business name during the last 5 years
(select if yes)
Number of
owners
Number full time
employees
Number part time
employees
Annual Payroll
Owners $
Employees $
Total annual Gross
Receipts.
Building
Square Footage
Briefly
describe your business and what you do.
Underwriting Information
Current Insurance
(not
agency)
Expiration Date
Describe any
losses within the last three years, amounts paid on any
claims, or other information we should be aware of when
generating this quote?
Liability Coverage Desired
Limits of
Liability Needed
If "Other", please explain below
Please
include any explanations, special requirements, or information
that you believe might influence this quote:
This online form is provided for
your convenience only.
Any changes will not be construed as
binding until you have received a confirmation from Yarmouth Insurance
Agency. Due to any
one individual or agency's lack of control over the Internet as a
whole, Yarmouth Insurance Agency can not be held responsible for any
delays in electronic communications.
Thank you for taking the time to
complete this form.
We will contact you as soon as possible..
Please Notice: Yarmouth Insurance Agency cannot
bind, modify or cancel coverage via submissions to our website, or by
messages sent through e-mail. Completion and submission of this form or
e-mail does not constitute either a binder or an application for
insurance. This site provides quotes and information only. An application
signed by you and our agent is required for insurance to become effective.
