Orr and Associates
Inland Marine Quote-Request Form
So that we may better serve you, fill out as completly as possible.
|
Name |
|
|
Telephone |
|
|
TR>
Owners Name |
|
|
<
/TR>
Company Name |
|
|
Estimated Annual Gross Receipts |
|
|
TR>
Estimated Annual Employee Payroll in the
Field |
|
|
Estimated Annual sub-out costs |
|
|
Liability Limit |
|
|
Number of years in business |
|
|
Current Policy Exp Date |
|
|
Description of kind of work.
Example:
Re-modeler
Plumber
Home Builder |
|
|
License Type |
|
|
Current carrier |
|
|
Any
Claims in past 3 years |
|
|
Fax
number |
|
|
Email |
|
|
Address |
|
|
Please describe what you are interested
in: |
|
|
|
We will contact you shortly with a
quote. |