Forms

New Customer Form

Applications can be completed online, or you can print the PDF, complete, and fax to: (334) 636-9830.

Company Name

Company Address

Contact Email

Federal Identification # or Social Security #

Phone Number

Contact Person

How many years in business?

Is Business Mechanized?

What Lines of Insurance?
W/CGeneral LiabilityAutoI/M

Estimated Production (only if interested in W/C of GL)

Payroll

Renewal Date(s)

WC (3 yrs)

GL (3 yrs)

Auto (4-5 yrs)

I/M (5 yrs)