Private Investigator / Insurance Adjuster / Process Server Insurance Quick Quote Request Form from AMIS Insurance

Applicant Information

First Name

M.I.

Last Name

Business Name

Website

Yes No

Do you operate from a residence?

NOTE: Business address must be a street address - NO PO BOXES.

Business Street Address

City

State

Zip Code

Mailing Address

If both addresses are the SAME, please leave MAILING Address BLANK.

City

State

Zip Code

Email Address

Business Phone

- -

Home Phone

- -

Mobile Phone

- -

Fax Number

- -

Information About Your Business

State License Number

Entity Type (if applicable)

Corporation

Individual

Partnership

LLC

Other

Date Business Established

Years of Experience

Details of Experience (Max 150 chars)

Professional Association

No. Owners/Officers

No. Employees

No. Consultants

Est. Annual Payroll

$

Employees only; No Owners/Partners/Clerical.

Est. Annual Gross Sales

$

Subcontractors (Insured)

$

1099 Labor (Uninsured)

$

Percentage of Each Type of Work Performed

Please enter the percentage for each activity.

Total must equal 100%

Operation Total:

0%

% Activity Check

% AOE/COE

% Attorney Service

% Background

% Civil

% Claims Adjuster

% Computer Fraud

% Criminal

% Domestic

% Fidelity

% Forensic Invest.

% Locates/Skip

% Medical Malprac.

% Mystery Shopping

% Polygraph

% Process Service

% Product Liab.

% Property/Arson

% Public Adjuster

% Record Retr.

% Sub-Rosa

% Consultant

% Other

If Other or Consultant, describe in detail:

Limit: 150 characters.

Indicate on Behalf of Whom These Services Are Performed

Please enter the percentage for each activity.

Total must equal 100%

Behalf Of Total:

0%

% Insurance Carriers

% Law Firms

% NBA

% NFL

% Private Parties

% Public Entities

% Self Insureds

% Other

Description limit: 150 characters.

Claims or Public Adjusters

Yes No

Do you do claims or public adjusting?

Selecting "Yes" will reveal additional adjuster details below.

If YES, please complete this section:

Number of Outside Adjusters

Number of Inside Adjusters

Yes No

Are you bonded?

Selecting "Yes" will reveal additional details to submit.

Yes No

Do you extend "hold harmless" toward any of your accounts or other entities?

Selecting "Yes" will reveal additional details to submit.

Yes No

Do you set reserves of claims?

Selecting "Yes" will reveal additional details to submit.

Yes No

Do you have draft or check issuance authority?

Selecting "Yes" will reveal additional details to submit.

Claims / Public Adjuster Income Sources

Please enter the percentage for each activity.

Total must equal 100%

Income Sources Total:

0%

% Insurance Carriers

% Law Firms

% Public Adjusting

% Risk Retention Groups

% Self Insureds

% Third Party Admins.

% Other

Limit: 255 characters.

Claims / Public Adjuster Income Areas

Please enter the percentage for each activity.

Total must equal 100%

Income Areas Total:

0%

% Casualty

% Ocean Marine

% Env. Liability

% Property

% Inland Marine

% Workers' Comp

% Other

Limit: 255 characters.

Desired Terms for Quote

Requested Effective Date

/ /

(MM/DD/YYYY)

Deductible

$0 Per Claim

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

Yes No

Any claims in the last five years?

Selecting "Yes" will reveal additional details to submit.

Yes No

Do you currently have insurance?

Selecting "Yes" will reveal additional details to submit.

Licensed Agent / Broker Information

Yes No

Are you a licensed insurance agent or broker?

Selecting "No" will reveal additional details to submit.

If YES, please complete this section:

Producer (Agent/Broker Name):

Insurance Agency Name:

Email Address:

Notice: 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.

Yes No

Did you previously provide your agency information to AMIS?

Selecting "No" will reveal additional details to submit.

Comments & Priority

Comments or Additional Info:

Maximum 200 characters

Please Prioritize Your Request:

Hurry! I need it ASAP!

Please quote prior to my renewal

No hurry, just checking

Declarations and Legal Notices

Terms of Use & Declaration:

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.

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.

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.

Do you agree to the above? *

This constitutes your digital signature.

Yes No