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Business Quote Request Form - (Texas Residents Only!)
(* Indicates a required field)
All information provided will be regarded as strictly confidential, and will be used only to secure an accurate quotation for insurance coverage.
Named Insured:
Coverage Info:
*Full Name:
Nature/Type of Business:
*Contact Phone:
Cell #
Commercial Auto:
General Liability:
Fax:
Web URL:
# of Locations:
*see below
Workers Comp: Umbrella: Other:
*Email: (EIA use only)
Current Carrier: Expire Date:
*Mailing Address: Address: City:
State: Zip: County:
Referred by:
Business Address: Same as Mailing Address
Add: City:
Business Information:
Full Time: Part Time:
# of Bus. Owned Vehicles:
Any Business use of Employee owned vehicles: No Yes If yes, how many:
* If yes, please supply details below in Comments/Remarks section
Loss Information:
Have you had any losses in the last three years? Describe:
Other Locations:
List other locations you have:
Comments/Remarks:
Submission of quote request form to Elzey Insurance Agency does not constitute a binding confirmation of new or revised insurance coverage. To confirm binding or policy revision you must receive verbal or written confirmation from a licensed E.I.A. representative.
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