Reeves and Melvin Insurance & Real Estate

Binding Agreement

(Required) I understand that any policy changes and quote requests are effective only when I have received a written confirmation.*

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Your Contact Information

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Email Address:*

Phone Number:*

How would you like us to follow up with you?*

Email Phone

Business Address

Address 1:*

Address 2:

City:*

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Current and Requested Insurance Coverage

Does your business currently carry Workers Compensation Insurance?*

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If yes, who is the insurance company?

What is the expiration date of your current policy?

What is the approximate premium for your current policy?

Does your business have Group Health Insurance?*

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Workers Compensation Insurance Limit Requested:

Information About Your Business

Business Name:*

FEIN:

Type of Business Entity:*

Please describe your business:*

Number of Full Time Employees:*

Number of Part Time Employees:*

Annual Payroll:*

Annual Gross Receipts:*

Number of Locations:*

How long have you been in business?*

Is there any information about your business you would like to add?

Other Coverage You May Need

Any other comments or information?

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This submission is a request. Insurance coverage changes and new coverages are not effective until we confirm that for you.

We will do our best to furnish a quote based on the information you provide. The more complete your information, the more accurate your quote will be.

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