Poulton Associates, Inc. :: Insurance Risk Management

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Create a Custom Insurance Application:
Based on the information you give us in this form, we will create a customized insurance application for your insurance needs.

Information on your application will be electronically encrypted for confidentiality and security.

* Denotes Required Field.

*	Name:	*	E-mail:
*	Address:		2nd Address:
*	City:	*	State:
*	Zip:	*	Phone:
	Fax:		Company:

Product Liability Information:

In how many buildings do you own or occupy space?


How many products and/or services (or categories of them) do you sell?


How many products to be covered by this insurance have you discontinued or are considering discontinuing?


Are you a contractor?
YesNo

Are you looking for Worker's Compensation Insurance?:
Yes No
If "yes": In how many locations?

Automobile Fleet Coverage	Yes No
If "yes": For how many automobiles,
and how many drivers?

Please select your primary line of business:

Other Information:


How many insurance policies do you now carry?


How many losses have you had in the last 3 years?

(On any kind of policy we will request details.)