Saperstein Agency, Inc. -- Manufacturer's Program Quote Form

Saperstein Agency, Inc.


MANUFACTURER'S INSURANCE PROGRAM		We would like to provide you with a free, no-obligation manufacturer's insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only. We will contact you when this is received to discuss your insurance needs more adequately.

General Information
Name of Business:
Contact Name:	Position:
Address:
City:	State: Zip:
Business Phone:	Fax:
Best Time To Call:	AM PM
Business WebSite Address:	http://
*Contact Email Address (Required):

Current Insurance Information

Insurance Company Name
(not agency):

Policy Expiration Date:

Premium Amount: $

What type of coverage's are you interested in?

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 employees	# of company vehicles	How long in business	How many locations	Annual sales
		years		$
Please give a brief description of the products that you manufacture:

Please Answer the Following Questions
to enable us to serve you better

Please indicate your concern regarding your current insurance protection:

Price
Too Much Coverage
Too Little Coverage

Insurance Company/Agency not familiar
with your business or household need

How would you rate the service that your current agent/broker provides:

Excellent

Adequate

Poor

If you could change one thing about your current insurance protection, what would it be:

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough space, please enter them here.

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.