Insurance Quick Quote

Private Investigators, Insurance Adjusters, Accident Reconstructionists, Forensic
Investigators, Background & Record Retrievers, Attorney Services, and Process Servers

FOR MORE INFORMATION ABOUT THIS INSURANCE PROGRAM, CLICK THE APPROPRIATE JOB TITLE ABOVE.

First Name:	Middle Initial: Last Name:
Business Name:
Website:

Do you operate from a residence?	Yes No
	THE BUSINESS ADDRESS MUST BE A STREET ADDRESS - NOT A PO BOX.
Business Address:
City:	State: Zip Code:
	If both addresses are the SAME, please leave MAILING Address BLANK.
Mailing Address:
City:	State: Zip Code:

Email Address:

Business Phone:	- -	Home Phone:	- -
Mobile Phone:	- -	Fax Number:	- -

Information About Your Business

State License Number and Type:

(if applicable)

Corporation	Partnership	Limited Liability Corp (LLC)
Individual	Other - Explain:

Date Business was Established:

Years of Experience:

Brief Details of Experience:

(150 characters)

Professional Association:

Number of Owners/Officers/Partners:

Number of Employees:

Number of Security Consultants:

Estimated Annual Payroll: $

EMPLOYEES ONLY; Not Owners, Partners, Officers or Clerical

Estimated Annual Gross Sales: $

Amt. Paid to Subcontractors/Vendors: $

(For subcontractors / vendors who DO have insurance)

1099 Labor: $

(For subcontractors / vendors who do NOT have insurance)

Percentage of Each Type of Work Performed

Total must equal 100%

% Activity Check	% Criminal	% Polygraph
% AOE/COE	% Domestic	% Process Service
% Attorney Service	% Fidelity	% Product Liability
% Background	% Forensic Investigation	% Property/Arson
% Civil	% Locates/Skip Tracing	% Public Adjuster
% Claims Adjuster	% Medical Malpractice	% Record Retrievers
% Computer Fraud	% Mystery Shopping	% Sub-Rosa

% Consultant ***	*** If Other or Consultant, describe in detail:
% Other ***	(150 characters)

Indicate on Behalf of Whom These Services Are Performed

Total must equal 100%

% Insurance Carriers	% Law Firms	% NBA
% NFL	% Private Parties	% Public Entities
% Self Insureds	% Other (describe in detail below)
	(150 characters)

Claims or Public Adjusters

Do you do claims or public adjusting? Yes No


	If YES, please complete this section.

	Number of Outside Adjusters:	Number of Inside Adjusters:

	Yes No	Are you bonded? If so, for what amount?
	Yes No	Do you extend "hold harmless" toward any of your accounts or other entities? If yes, to whom are they extended? (50 characters)
	Yes No	Do you set reserves of claims? If yes, please give details: (100 characters)
	Yes No	Do you have draft or check issuance authority?

	If YES, please list for what companies and what amounts:

	Company	Amount

Claims / Public Adjuster Income Sources

Total must equal 100%

% Insurance Carriers	% Law Firms	% Public Adjusting
% Risk Retention Groups	% Self Insureds	% Third Party Admins.
% Other - please describe:	(255 characters)

Claims / Public Adjuster Income Areas

Total must equal 100%

% Casualty	% Environmental Liability	% Inland Marine
% Ocean Marine	% Property	% Workers' Compensation
% Other - please describe:	(255 characters)

Desired Terms for Quote

Requested Effective Date for New Policy: / / (M / D / YYYY)

Limits of Liability:	$300,000	$500,000	$1,000,000/$2,000,000
	$1,000,000/$5,000,000	$2,000,000	$2,000,000/$3,000,000
	$2,000,000/$5,000,000	$3,000,000	$3,000,000/$5,000,000
	$4,000,000	$5,000,000	$6,000,000/$7,000,000

Deductible:	$0 Per Claim

How many 30-Day Notice of Cancellation certificates?		($150 plus taxes each)
Non-Owned & Hired Auto ( $1,000,000 Max.)	Yes No	($150 plus taxes) (Excess over employee's $25,000 personal auto)

Current Insurance Information

Any claims in the last five years?	Yes No NOTE: We will need loss runs prior to binding coverage.

If claims in the last five years - explain:	(200 characters)

Do you currently have insurance?	Yes No

	If YES, please complete this section.
Prior or Current Insurance Company:		Policy Number:
Policy Limit: $		Premium Amount: $

Licensed Agent / Broker Information

Are you a licensed insurance agent or broker?	Yes No

	If YES, please complete this section.
Producer (Insurance Agent/Broker):
Insurance Agency Name:
Email Address:

Prior to binding any coverage with AMIS, we must have a signed Broker Agreement, a copy of your Broker/Insurance License, and a copy of the declaration page of your E & O Insurance policy. Click here for more information.
Did you previously provide your agency information to AMIS?	Yes No

	If NO, please complete this section.
Agency License Number:
Street Address:
City:	State: Zip Code:
Contact Person Phone:	- -
Name of E&O Insurance Company:
E&O Policy Number:
E&O Policy Expiration Date:	/ / (M / D / YYYY)

Comments, Priority, Terms of Use

Comments or Additional Info:	(200 characters)

Please Prioritize Your Request:	Hurry! I need it ASAP! Please quote prior to my renewal No hurry, just checking

By submitting this quick quote application, you declare that:

the information you are providing is accurate and complete to the best of your knowledge and belief
you have read and agree to our underwriting conditions
you have read and agree to our Fraudulent Acts Notice
you have read and agree to our California Notice (CA businesses only)
you have read and agree to our International Operations Notice
you have reviewed and confirm as true, correct and complete each of the representations and warranties and all other information set forth in the application.

Depending on the size of the risk, a full completed application may be required in order to receive a formal quotation prior to binding coverage. AMIS may elect to withdraw any indication quote upon review of a full completed application if the application does not meet the underwriting guidelines of the insurance company. Click here to view the underwriting conditions.

AMIS/Alliance Marketing & Insurance Services does not warrant or guarantee suitability or adequacy of coverage in meeting any generic, specific or contractual requirements of any insurance company, state, county, corporation, public entity, or public party that you may provide services to during the policy period, including any written or oral request forwarded to AMIS or its staff. You assume the risk of obtaining suitable or adequate coverage to meet any generic, specific or contractual requirements of your client or company. The information contained herein is provided with the understanding the AMIS is not engaged in rendering legal services, including legal opinions or advice, or professional risk management consulting. If legal services or professional services are required, you will need to seek the advice of legal counsel.

You agree:	Yes NoNOTE: This constitutes a digital signature.

ATTENTION: You must click the Submit button to complete this request for a quote.
Please wait for an acknowledgement before closing your browser or window.

NOTE: An application or information form is not an insurance policy and does not bind any coverage. All applications must be underwritten and a quotation will be issued subject to underwriting guidelines. The quotation does not bind coverage.

Insurance Quick Quote

Private Investigators, Insurance Adjusters, Accident Reconstructionists, Forensic Investigators, Background & Record Retrievers, Attorney Services, and Process Servers

FOR MORE INFORMATION ABOUT THIS INSURANCE PROGRAM, CLICK THE APPROPRIATE JOB TITLE ABOVE.

Information About Your Business

Percentage of Each Type of Work Performed

Indicate on Behalf of Whom These Services Are Performed

Claims or Public Adjusters

Claims / Public Adjuster Income Sources

Claims / Public Adjuster Income Areas

Desired Terms for Quote

Current Insurance Information

Licensed Agent / Broker Information

Comments, Priority, Terms of Use

Private Investigators, Insurance Adjusters, Accident Reconstructionists, Forensic
Investigators, Background & Record Retrievers, Attorney Services, and Process Servers