Quote Request
Merit to prepare and send a quote based on this information
Agent Name
First Name
Last Name
Brokerage Name
Requester Email Address
example@example.com
Requester Phone Number
-
Area Code
Phone Number
Customer Name
First Name
Last Name
Customer Entity Name, if applicable
Effective Date
-
Month
-
Day
Year
Date
Insurer/ Insurance Company
Premium Amount
Policy Fee Amount
Tax Amount
Minimum Retained Amount
Policy Type
Number of Payments Requested
Term of Policy
Urgency/ Date or Time Quote Needed
Other Optional Information to Advise for Quote (select as many as apply)
Customer Email
Customer Tel Number
Customer Address
Prefer Continuous
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Continuous Plan
Upload Dec Page, Preliminary Quote, or Other Documentation
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