Forms

New Customer Form

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

View / Print PDF

Complete Online

Company Name

Company Address

Contact Email

Federal Identification # or Social Security #​

Phone Number

Contact Person

How many years in business?

Is Business Mechanized?​
YesNo

What Lines of Insurance?
W/CGeneral LiabilityAutoI/M

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

Payroll

Renewal Date(s)

Prior Carrier(s):

WC (3 yrs)

GL (3 yrs)

Auto (4-5 yrs)

I/M (5 yrs)

Auto Information

List of Units

#	Year	Make	Model	VIN #	St. Amount
1
2
3
4
5

List of Drivers

#	Name	DOB	License #	State
1
2
3
4
5

List of Equipment

#	Year	Make	Model	Serial #	Current St. Amount
1
2
3
4
5