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:
Current/Previous Insurance Information
Company
Name (not an agency):
Policy
Expiration Date:
Premium Amount: $
Losses
or Claims in last 5 yrs.
number
of claims Total amount of
claims $
Details of any
claims/losses from previous question:
General
Business Information
Number of
full-time employees
Number
of part-time employees
Number
of locations
Estimated
Annual Payroll$
Business
Type:
Number
years in business
Limits
of Liability needed :
Briefly
describe your business below, and types of work being performed
by each employee:
(example - House Painting - int./ext., 1-office staff, 5
painters, 1 estimator)
Please include any
additional information that we should be aware of when preparing
the insurance quote you have requested
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.
