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BUSINESS INSURANCE QUOTE REQUEST

We would like to provide you with a free, no-obligation business insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

Business Name:  
Contact:  
Address:  
City:      State:    Zip: 
Business Phone:  
E-mail:  
URL:  

CURRENT INSURANCE INFORMATION

Company Name (not agency):  
Policy Expiration Date:   Premium Amount: $

What types of coverage do you currently have?
  Bond   Commercial Umbrella   Group Life
  Commercial Auto   Directors and Officers Liability   Professional Liability
  Commercial Liability   Disability   Workers' Compensation
  Commercial Property   Group Health   Other

ABOUT YOUR BUSINESS

Full-Time Employees Part-Time Employees Years in Business Number of Locations Annual Sales
$
Please give a brief description of your business and clientele:

COVERAGE INFORMATION

Please list the types of coverage you desire:
  Bond   Commercial Umbrella   Group Life
  Commercial Auto   Directors and Officers Liability   Professional Liability
  Commercial Liability   Disability   Workers' Compensation
  Commercial Property   Group Health   Other

ADDITIONAL INFORMATION

Please list below any information that you feel may be relevant to this quote, or use this space to expound on anything listed above.

    

 
COMMERCIAL LINES DEPARTMENT EXTENSION E-MAIL ADDRESS
Jay Binsfeld, JD, CIC CEO 112
Allan N Yont, CPCU President-General Manager 119 allany@generalsouthwest.com
Joe Binsfeld, CIC Executive Vice President 115 joeb@generalsouthwest.com
David Binsfeld, CIC, LUTCF, ARM, Vice President 132 daveb@generalsouthwest.com
Brittany Miller 122 brittanym@generalsouthwest.com
Marie Davis-Anderson, CISR 120 maried@generalsouthwest.com
Reina Williams 103 reinaw@generalsouthwest.com
Sandra Shanks, CISR 123 sandras@generalsouthwest.com
Shanna Crownover 137 shannac@generalsouthwest.com
Sarah Nuriddin, Select Accounts Sales and Service 129 sarahn@generalsouthwest.com
Stacy Ortiz, CISR, Select Accounts Sales and Service 113 stacyo@generalsouthwest.com
Julie Slisko, Select Accounts Assistant 139 julies@generalsouthwest.com
Denise DeFusco, Transportation Ins. 121 denised@generalsouthwest.com
     
5628 East Thomas ~ Phoenix, Arizona 85018 ~ 480-990-1900 ~ FAX: 480-481-9551
joeb@generalsouthwest.com ~ US Postal Address: P. O. Box 98 Scottsdale, Arizona 85252
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