Inland Marine Coverage

Inland Marine Coverage Form

First Name:

Last Name:

Phone:

Email:

Business Name:

Legal Entity Type:

Federal EIN:

Business Address:

Date business was established:

Years in Business:

Years of Experience:

Number of Full Time Employees:

Number of Part-Time Employees:

Brief Description of Business:

Estimated Gross Revenue:

Estimated Payroll for Next 12 Months:

Do you have insurance right now?

Yes

If Yes, how long have you had it?

What type of coverages are you looking for (select all that apply):

General Liability

Professional Liability

Workers Comp

Cyber

Inland Marine

Umbrella

Business Owners Policy

Business Auto Policy

Commercial Auto

Event Liability

Surety Bond

Auto

Home

Dwelling Fire

Renters

Life

Cycle

ATV

Boat

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Contact Us

3329 W Sunset Ave. STE B,

Springdale AR 72762

479-318-2775

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