Personal Information
Name:
Address (city, state, zip code)
E-mail:
Telephone:
Fax:
Best time to call:
Coverage Information
Type of business:
Please select:
Office
Service
Retail
Wholesale
Apartments
Condominium
Number of employees:
Full-time
Part-time
Annual Payroll:
How long in business:
years
Approximate annual sales:
Please provide a brief description of your business and clientele:
Coverage Options
Coverages:
Commercial Auto
General Liability
Commercial Property
Business Personal Property
Computer Coverage
Umbrella
Workers' Compensation
Other
Comments and additional pertinent information:
Submitting an insurance quotation request to Garrett-Lynch Insurance Agency does not constitute a binding confirmation of new or altered insurance coverage. Verbal or written confirmation must be obtained from Garrett-Lynch Insurance Agency to confirm binding or altering coverage.
If you have any questions or have trouble filling out this form please
contact us
.
