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    If You Represent A Company Please Enter Firm Name        Position/Title          

  *Address Street City                       State    Zip Code
  Telephone Numbers *Tel: AC   #     Cell: AC #


  *Select Type  Insurance Coverage  Requested
Commercial / Business Insurance Personal Insurance

Business Owners Policy 

 Package Policy / Building / Contents / Business Interruption (Loss of Income- Extra Expense) / Liability

General Liability or Contractors Liability

Umbrella Liability

Professional Liability ( Malpractice / E&O )

Business Property Insurance

Package Policy / Building / Contents / Business Interruption (Loss of Income- Extra Expense)

Flood ( Commercial Property )

Wind / Hail Policy ( Coast Risks Only )

Workers Compensation Insurance

Commercial Auto / Truck (s) / Fleet

Cargo ( Inland or Marine )

Heavy Equipment           

Other - Please specify or describe below:


Auto / Car Insurance

Homeowners / Renters / Condo   

Flood ( Personal Property )

Mobile Home ( Pre-Manufactured)      

Motor Home / Camper / RV 

Motor Cycle / ATV      

Watercraft - Boat / Jet Ski

Other - Please specify or describe below:





 *Customers usually receive from 3 to 5 quotes from different insurers.
Companies providing quotes may vary.


What It Means to Be a CIC - The Certified Insurance Counselor (CIC) designation is a distinction that represents a commitment to professional excellence and leadership within the insurance industry. The 30,000+ designated CICs across the country are recognized as among the best and most knowledgeable insurance practitioners in the nation. The formal training required to become a CIC includes 100 classroom hours and the successful completion of five comprehensive exams, with an annual update required to ensure that CICs maintain their edge as the most capable and current insurance practitioners in the industry.

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