Andre-Romberg Business Quote Request


General Information
Name of Business:
Contact Name:
Street Address:
City:   State:   ZIP:
County:   Email:
Business Phone: ( ) -            Fax: ( ) -
Best time to call:   AM   PM
Current Insurance Company (not agency):
Company Name:
Policy Exp. Date:
 		 / /
 
What type of coverages do you currently have:
Bond
Commercial Auto
Commercial Liability
Commercial Property		 Commercial Umbrella
Directors & Officers Liability
Disability
Group Health		 Group Life
Professional Liability
Workers' Compensation
Other  
About Your Business:
# of full-time employees # of part-time employees How long in business How many locations Annual Sales
yrs. $


Please give a brief description of your business and clientel:


Please select the type of coverages you want:
Bond
Commercial Auto
Commercial Liability
Commercial Property		 Commercial Umbrella
Directors & Officers Liability
Disability
Group Health		 Group Life
Professional Liability
Workers' Compensation
Other  
Additional Comments:
Please give any additional comments about the coverage you desire:
 

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E-mail: info@andre-romberg.com | 400 S. Jefferson Suite #333, Spokane, WA 99204

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